0001005477-05-000487.txt : 20120725 0001005477-05-000487.hdr.sgml : 20120725 20050208171007 ACCESSION NUMBER: 0001005477-05-000487 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 2 FILED AS OF DATE: 20050208 DATE AS OF CHANGE: 20050208 GROUP MEMBERS: BLOCH, SUSAN SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: FORMFACTOR INC CENTRAL INDEX KEY: 0001039399 STANDARD INDUSTRIAL CLASSIFICATION: SEMICONDUCTORS & RELATED DEVICES [3674] IRS NUMBER: 133711155 STATE OF INCORPORATION: DE FILING VALUES: FORM TYPE: SC 13G/A SEC ACT: 1934 Act SEC FILE NUMBER: 005-79547 FILM NUMBER: 05584808 BUSINESS ADDRESS: STREET 1: 7005 SOUTHFRONT ROAD CITY: LIVERMORE STATE: CA ZIP: 94551 BUSINESS PHONE: 9252433522 MAIL ADDRESS: STREET 1: 7005 SOUTHFRONT ROAD CITY: LIVERMORE STATE: CA ZIP: 94551 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: KHANDROS IGOR Y CENTRAL INDEX KEY: 0001256946 FILING VALUES: FORM TYPE: SC 13G/A BUSINESS ADDRESS: BUSINESS PHONE: 9252904000 MAIL ADDRESS: STREET 1: 7005 SOUTHFRONT ROAD CITY: LIVERMORE STATE: CA ZIP: 94551 SC 13G/A 1 file001.txt AMENDMENT NUMBER 1 TO SCHEDULE 13G SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 SCHEDULE 13G Rule 13d-102 Under the Securities Exchange Act of 1934 (Amendment No. 1)* FORMFACTOR, INC. -------------------------------------------------------------------------------- (Name of Issuer) Common Stock -------------------------------------------------------------------------------- (Title of Class of Securities) 346375 10 8 -------------------------------------------------------------------------------- (CUSIP Number) 12/25/2004 -------------------------------------------------------------------------------- (Date of Event which Requires Filing of this Statement) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: |_| Rule 13d-1 (b) |_| Rule 13d-1 (c) |X| Rule 13d-1 (d) ---------- * The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter disclosures provided in a prior cover page. The information required on the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). Page 1 of 5 Pages CUSIP No. 346375 10 8 -------------------------------------------------------------------------------- (1) Names and I.R.S. Identification Nos.(entities only) of reporting persons. KHANDROS, IGOR Y -------------------------------------------------------------------------------- (2) Check the appropriate box if a member of a group (see instructions) (a)|_| (b)|_| -------------------------------------------------------------------------------- (3) SEC use only. -------------------------------------------------------------------------------- (4) Citizenship or place of organization. USA -------------------------------------------------------------------------------- Number of shares beneficially owned by each reporting person with: (5) Sole voting power: -0- (6) Shared voting power: 3,525,658 (1) (7) Sole dispositive power: -0- (8) Shared dispositive power: 3,525,658 (1) -------------------------------------------------------------------------------- (9) Aggregate amount beneficially owned by each reporting person. 3,525,658 (1) -------------------------------------------------------------------------------- (10) Check if the aggregate amount in Row (9) excludes certain shares |_| (see instructions). -------------------------------------------------------------------------------- (11) Percent of class represented by amount in Row 9. 9.1% -------------------------------------------------------------------------------- (12) Type of reporting person (see instructions). IN -------------------------------------------------------------------------------- ---------- (1) Represents (i) 2,225,658 shares held directly by Igor Khandros, of which 104,228 shares are issuable upon exercise of stock options that are exercisable within 60 days of December 25,2004 and 100,000 are unvested shares that are, as of December 25, 2004, subject to the Company's lapsing right of repurchase at the initial purchase price for these shares, and (ii) 1,300,000 shares held by Susan Bloch, Mr. Khandros' spouse. Excludes 100,000 shares subject to a stock option granted to Mr. Khandros, which is exercisable as it vests, that vests 1/12th of the total number of shares each month starting on April 15, 2006, and 30,000 shares subject to a stock option granted to Mr. Khandros, which is exercisable as it vests, that vests 1/12th of the total number of shares each month starting on April 15, 2007. Also excludes 365,000 shares held by The Khandros 1997 Trust I U/T/A dated March 28, 1997, and 365,000 shares held by The Khandros 1997 Trust II U/T/A dated March 28, 1997. The information disclosed in this footnote also applies to Items 4(a),(c)(ii) and (c)(iv) of this Schedule 13G/A. Page 2 of 5 Pages CUSIP No. 346375 10 8 -------------------------------------------------------------------------------- (1) Names and I.R.S. Identification Nos.(entities only) of reporting persons. BLOCH, SUSAN -------------------------------------------------------------------------------- (2) Check the appropriate box if a member of a group (see instructions) (a)|_| (b)|_| -------------------------------------------------------------------------------- (3) SEC use only. -------------------------------------------------------------------------------- (4) Citizenship or place of organization. USA -------------------------------------------------------------------------------- Number of shares beneficially owned by each reporting person with: (5) Sole voting power: -0- (6) Shared voting power: 3,525,658 (1) (7) Sole dispositive power: -0- (8) Shared dispositive power: 3,525,658 (1) -------------------------------------------------------------------------------- (9) Aggregate amount beneficially owned by each reporting person. 3,525,658 (1) -------------------------------------------------------------------------------- (10) Check if the aggregate amount in Row (9) excludes certain shares |_| (see instructions). -------------------------------------------------------------------------------- (11) Percent of class represented by amount in Row 9. 9.1% -------------------------------------------------------------------------------- (12) Type of reporting person (see instructions). IN -------------------------------------------------------------------------------- ---------- (1) Represents (i) 2,225,658 shares held directly by Igor Khandros, of which 104,228 shares are issuable upon exercise of stock options that are exercisable within 60 days of December 25,2004 and 100,000 are unvested shares that are, as of December 25, 2004, subject to the Company's lapsing right of repurchase at the initial purchase price for these shares, and (ii) 1,300,000 shares held by Susan Bloch, Mr. Khandros' spouse. Excludes 100,000 shares subject to a stock option granted to Mr. Khandros, which is exercisable as it vests, that vests 1/12th of the total number of shares each month starting on April 15, 2006, and 30,000 shares subject to a stock option granted to Mr. Khandros, which is exercisable as it vests, that vests 1/12th of the total number of shares each month starting on April 15, 2007. Also excludes 365,000 shares held by The Khandros 1997 Trust I U/T/A dated March 28, 1997, and 365,000 shares held by The Khandros 1997 Trust II U/T/A dated March 28, 1997. The information disclosed in this footnote also applies to Items 4(a),(c)(ii) and (c)(iv) of this Schedule 13G/A. Page 3 of 5 Pages Item 1(a). Name of Issuer: FORMFACTOR, INC. Item 1(b). Address of Issuer's Principal Executive Offices: 7005 SouthFront Street Livermore, CA 94551 Item 2(a). Name of Person Filing: KHANDROS, IGOR Y Item 2(b). Address or Principal Business Office or, If None, Residence: c/o FormFactor, Inc. 7005 SouthFront Street Livermore, CA 94551 Item 2(c). Citizenship: USA Item 2(d). Title of Class of Securities: Common Stock Item 2(e). CUSIP No.: 346375 10 8 Item 3. If This Statement is Filed Pursuant to Rule 13d-1(b), or 13d-2(b) or (c), Check Whether the Person Filing is a: (a) |_| Broker or dealer registered under section 15 of the Act (15 U.S.C. 78o). (b) |_| Bank as defined in section 3(a)(6) of the Act (15 U.S.C. 78c). (c) |_| Insurance company as defined in section 3(a)(19) of the Act (15 U.S.C. 78c). (d) |_| Investment company registered under section 8 of the Investment Company Act of 1940 (15 U.S.C 80a-8). (e) |_| An investment adviser in accordance with ss. 240.13d-1(b)(1)(ii)(E); (f) |_| An employee benefit plan or endowment fund in accordance with ss.240.13d-1(b)(1)(ii)(F); (g) |_| A parent holding company or control person in accordance with ss.240.13d- 1(b)(1)(ii)(G); (h) |_| A savings associations as defined in Section 3(b) of the Federal Deposit Insurance Act (12 U.S.C. 1813); (i) |_| A church plan that is excluded from the definition of an investment company under section 3(c)(14) of the Investment Company Act of 1940 (15 U.S.C. 80a-3); (j) |_| Group, in accordance with ss. 240.13d-1(b)(1)(ii)(J). If this statement is filed pursuant to Rule 13d-1(c), check this box. |_| Item 4. Ownership (a) Amount beneficially owned: 3,525,658 (b) Percent of class: 9.1% (c) Number of shares as to which such person has: (i) Sole power to direct the vote -0- (ii) Shared power to direct the vote 3,525,658 (iii) Sole power to dispose or direct the disposition of -0- (iv) Shared power to dispose or direct the disposition of 3,525,658 Item 5. Ownership of 5 Percent or Less of a Class. If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than 5 percent of the class of securities, check the following |_| Item 6. Ownership of More than 5 Percent on Behalf of Another Person. N/A Item 7. Identification and Classification of the Subsidiary Which Acquired the Security Being Reported on by the Parent Holding Company or Control Person. N/A Item 8. Identification and Classification of Members of the Group. N/A Item 9. Notice of Dissolution of Group. N/A Item 10. Certifications N/A Page 4 of 5 Pages After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. Date: 02/08/2005 /s/ Igor Y. Khandros Name: Igor Y. Khandros Date: 02/08/2005 /s/ Susan Bloch Name: Susan Bloch The original statement shall be signed by each person on whose behalf the statement is filed or his authorized representative. If the statement is signed on behalf of a person by his authorized representative other than an executive officer or general partner of the filing person, evidence of the representative's authority to sign on behalf of such person shall be filed with the statement, Provided, however, That a power of attorney for this purpose which is already on file with the Commission may be incor porated by reference. The name and any title of each person who signs the statement shall be typed or printed beneath his signature. ATTENTION: Intentional misstatements or omissions of fact constitute Federal criminal violations (see 18 U.S.C. 1001). (Secs. 3(b), 13(d)(1), 13(d)(2), 13(d)(5), 13(d)(6), 13(g)(1), 13(g)(2), 13(g)(5), 23, 48 Stat. 882, 894, 901; sec. 203(a), 49 Stat. 704; sec. 8, 49 Stat. 1379; sec. 10, 78 Stat. 88a; sec. 2, 82 Stat. 454; secs. 1, 2, 84 Stat. 1497; secs. 3, 10, 18, 89 Stat. 97, 119, 155; secs. 202, 203, 91 Stat. 1494, 1498, 1499; (15 U.S.C. 78c(b), 78m(d)(1), 78m(d)(2), 78m(d)(5), 78m(d)(6), 78m(g)(1), 78m(g)(2), 78m(g)(5), 78w)) [43 FR 18499, Apr. 28, 1978, as amended at 43 FR 55756, Nov. 29, 1978; 44 FR 2148, Jan. 9, 1979; 44 FR 11751, Mar. 2, 1979; 61 FR 49959, Sept. 24, 1996; 62 FR 35340, July 1, 1997; 63 FR 2867, Jan. 16, 1998; 63 FR 15287, Mar. 31, 1998] Page 5 of 5 Pages EX-99.1 2 file002.txt JOINT FILING AGREEMENT EXHIBIT A TO SCHEDULE 13G/A Joint Filing Agreement Each of the undersigned hereby agrees that they are filing the attached statement containing the information required by Schedule 13G jointly under Rule 13d-1(k)(1) of the Securities Exchange Act of 1934, as amended, and that only one such statement needs to be filed with respect to the ownership by each of the undersigned of the securities of FormFactor, Inc. Dated: February 8, 2005 By:/s/ Igor Y. Khandros Igor Y. Khandros By:/s/ Susan Block Susan Bloch