0000950152-05-000773.txt : 20120705 0000950152-05-000773.hdr.sgml : 20120704 20050207092430 ACCESSION NUMBER: 0000950152-05-000773 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20050207 DATE AS OF CHANGE: 20050207 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: SHOPSMITH INC CENTRAL INDEX KEY: 0000089925 STANDARD INDUSTRIAL CLASSIFICATION: SPECIAL INDUSTRY MACHINERY (NO METALWORKING MACHINERY) [3550] IRS NUMBER: 310811466 STATE OF INCORPORATION: OH FISCAL YEAR END: 0403 FILING VALUES: FORM TYPE: SC 13G/A SEC ACT: 1934 Act SEC FILE NUMBER: 005-32158 FILM NUMBER: 05579049 BUSINESS ADDRESS: STREET 1: 6530 POE AVENUE CITY: DAYTON STATE: OH ZIP: 45414 BUSINESS PHONE: 5138986070 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: FOLKERTH JOHN R CENTRAL INDEX KEY: 0000901784 FILING VALUES: FORM TYPE: SC 13G/A BUSINESS ADDRESS: STREET 1: 131 FORRER BLVD CITY: DAYTON STATE: OH ZIP: 45414 BUSINESS PHONE: 5134634936 MAIL ADDRESS: STREET 1: 131 FORRER BLVD CITY: DAYTON STATE: OH ZIP: 45419 SC 13G/A 1 l11817bsc13gza.txt SHOPSMITH, INC. SC 13G/A SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 SCHEDULE 13G INFORMATION TO BE INCLUDED IN STATEMENTS FILED PURSUANT TO RULES 13d-1(b)(c), AND (d) AND AMENDMENTS THERETO FILED PURSUANT TO RULE 13d-2(b) (Amendment No. 23)* Shopsmith, Inc. ---------------------------------------- (Name of Issuer) Common Shares - No Par Value ---------------------------------------- (Title of Class of Securities) 825098 10 6 ---------------------------------------- (CUSIP Number) December 31, 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 the disclosures provided in a prior cover page. The information required in 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). (Continued on following page(s)) Page 1 of 5 Pages ====================== =================== CUSIP NO. 825098 10 6 13G Page 2 of 5 Pages ====================== =================== ================================================================================ 1 NAME OF REPORTING PERSON John R. Folkerth, Sr. -------------------------------------------------------------------------------- 2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) [ ] (b) [ ] -------------------------------------------------------------------------------- 3 SEC USE ONLY -------------------------------------------------------------------------------- 4 CITIZENSHIP OR PLACE OF ORGANIZATION U.S.A. -------------------------------------------------------------------------------- 5 SOLE VOTING POWER NUMBER OF 367,271 SHARES ---------------------------------------------- 6 SHARED VOTING POWER BENEFICIALLY 228,507 OWNED BY ---------------------------------------------- 7 SOLE DISPOSITIVE POWER EACH 367,271 REPORTING ---------------------------------------------- 8 SHARED DISPOSITIVE POWER PERSON 228,507 WITH -------------------------------------------------------------------------------- 9 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 595,778 -------------------------------------------------------------------------------- 10 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES* -------------------------------------------------------------------------------- 11 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW 9 22.7% -------------------------------------------------------------------------------- 12 TYPE OF REPORTING PERSON* IN ================================================================================ *SEE INSTRUCTION BEFORE FILLING OUT! Item 1. (a) Name of Issuer: Shopsmith, Inc. (b) Address of Issuer's Principal Executive Offices: 6530 Poe Avenue Dayton, Ohio 45414 Item 2. (a) Name of Person Filing: John R. Folkerth, Sr. (b) Address of Principal Business Office: 6530 Poe Avenue Dayton, Ohio 45414 (c) Citizenship: United States of America (d) Title of Class of Securities: Common Shares, without par value (e) CUSIP Number: 825098 10 6 Item 3. Rules 13d-1(b) or 13d-2(b) or (c) Statement. Not applicable. Item 4. Ownership. The following information concerning ownership of Common Shares is given as of December 31, 2004: (a) Amount Beneficially Owned: 320,212 shares directly owned 20,000 shares covered by options exercisable within 60 days 228,507 shares owned indirectly (by spouse) 27,059 shares owned indirectly (401(k) Plan) ------- 595,778 Total (b) Percent of Class: 22.7% (c) Number of shares as to which such person has: (i) sole power to vote or to direct the vote: 367,271 Common Shares (ii) shared power to vote or to direct the vote: 228,507 Common Shares (iii) sole power to dispose or to direct the disposition of: 367,271 Common Shares (iv) shared power to dispose or to direct the disposition of: 228,507 Common Shares Item 5. Ownership of Five Percent or Less of a Class. Not applicable. Item 6. Ownership of More than Five Percent on Behalf of Another Person. Not applicable. Item 7. Identification and Classification of the Subsidiary which Acquired the Security Being Reported on by the Parent Holding Company or Control Person. Not applicable. Item 8. Identification and Classification of Members of the Group. Not applicable. Item 9. Notice of Dissolution of Group. Not applicable. Item 10. Certification. Not applicable. Signature. 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: January 26, 2005 /s/ John R. Folkerth,Sr. ----------------------------------------- JOHN R. FOLKERTH, SR.