FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 12/15/2004 |
3. Issuer Name and Ticker or Trading Symbol
INTERLINE BRANDS, INC./DE [ IBI ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock(1) | 47,955 | D |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Option (Right) to buy Common Stock(2) | (3) | 05/16/2010 | Common Stock | 681 | (2) | D | |
Option (Right) to buy Common Stock(2) | 05/16/2005 | 05/16/2010 | Common Stock | 170 | (2) | D |
Explanation of Responses: |
1. Currently, the reporting person beneficially owns shares of common stock and preferred stock of Interline Brands, Inc., a New Jersey corporation ("Interline Opco"). In connection with the merger of Interline Opco with and into a wholly-owned subsidiary of Interline Brands, Inc., a Delaware corporation (the "Company"), each outstanding share of common stock of Interline Opco will be exchanged for 0.01142 shares of common stock of the Company; each outstanding share of preferred stock of Interline Opco issued on May 16, 2000 will be exchanged for 0.83115 shares of common stock of the Company; and each outstanding share of preferred stock of Interline Opco issued on September 29, 2000 will be exchanged for 0.78961 shares of common stock of the Company. In accordance with Rule 16b-7 promulgated under the Securities Exchange Act of 1934 (the "Exchange Act"), the exchange will be exempt under Section 16(b) of the Exchange Act. |
2. Currently, the reporting person holds options to purchase common stock of Interline Opco. Upon completion of the merger described above, and in accordance with the terms of the options, the options will automatically be converted into options to purchase shares of common stock of the Company. Of the options to purchase 851 shares of common stock held by the reporting person, options to purchase 284 shares have an exercise price of $146.23 per share, options to purchase 284 shares have an exercise price of $437.83 per share and options to purchase 283 shares have an exercise price $1,780.21 per share. |
3. Immediately. |
/s/ Laurence W. Howard, Attorney-in-Fact | 12/15/2004 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 5 (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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
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 Number. |