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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
APAX EUROPE IV GP CO LTD 13-15 VICTORIA ROAD, ST. PETER PORT GUERNSEY CHANN ISL, X0 GY1 3ZD |
X |
/S/ Andrew Guille as Alternate Director to Denise Fallaize, by power of attorney | 05/19/2005 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | On May 18, 2005, the Issuer's Common Stock split 31,013,482-for-1, resulting in Xerium 3 S.A. acquiring 31,013,481 additional shares of Issuer's Common Stock |
(2) | Pursuant to a Redemption Agreement between the Issuer and the Reporting Person, on May 19, 2005, the Issuer will redeem 2,125,663 shares of the Issuer's Common Stock from Xerium 3 S.A. in exchange for 43,757 shares of common stock of Xerium S.A., the indirect parent company of the Issuer |
(3) | Apax Europe IV GP Co. Limited (the "Reporting Person") is the Managing General Partner of Apax Europe IV GP, L.P., which is the Managing General Partner of Apax Europe IV-A, L.P., which as the indirect controlling shareholder of Xerium 3 S.A. may be deemed to be the beneficial owner of the shares of Issuer's Common Stock held by Xerium 3 S.A. The Reporting Person disclaims beneficial ownership of the securities reported herein except to the extent of its pecuniary interest therein |