0001866581-24-000018.txt : 20240125
0001866581-24-000018.hdr.sgml : 20240125
20240125214039
ACCESSION NUMBER: 0001866581-24-000018
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20240124
FILED AS OF DATE: 20240125
DATE AS OF CHANGE: 20240125
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Boersma Travis
CENTRAL INDEX KEY: 0001883154
ORGANIZATION NAME:
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40798
FILM NUMBER: 24563952
MAIL ADDRESS:
STREET 1: C/O DUTCH BROS INC.
STREET 2: PO BOX 1929
CITY: GRANTS PASS
STATE: OR
ZIP: 97528
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Dutch Bros Inc.
CENTRAL INDEX KEY: 0001866581
STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-EATING & DRINKING PLACES [5810]
ORGANIZATION NAME: 07 Trade & Services
IRS NUMBER: 871041305
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 110 SW 4TH STREET
CITY: GRANTS PASS
STATE: OR
ZIP: 97526
BUSINESS PHONE: (206) 390-8860
MAIL ADDRESS:
STREET 1: PO BOX 1929
CITY: GRANTS PASS
STATE: OR
ZIP: 97528-0163
4
1
wk-form4_1706236828.xml
FORM 4
X0508
4
2024-01-24
0
0001866581
Dutch Bros Inc.
BROS
0001883154
Boersma Travis
C/O DUTCH BROS INC.
110 SW 4TH STREET
GRANTS PASS
OR
97526
1
1
1
0
Executive Chairman of Board
0
Class A Common Stock
2024-01-24
4
C
0
324577
0
A
2514241
I
By DM Trust Aggregator, LLC
Class A Common Stock
2024-01-24
4
C
0
233333
0
A
1581186
I
By DM Individual Aggregator, LLC
Class B Common Stock
2024-01-24
4
C
0
324577
0
D
36458141
I
By DM Trust Aggregator, LLC
Class B Common Stock
2024-01-24
4
C
0
233333
0
D
22899005
I
By DM Individual Aggregator, LLC
Class B Common Stock
714080
I
By DMI Holdco LLC
Class A Common Units
2024-01-24
4
C
0
324577
0
D
Class A Common Stock
324577
36458141
I
By DM Trust Aggregator, LLC
Class A Common Units
2024-01-24
4
C
0
233333
0
D
Class A Common Stock
233333
22899005
I
By DM Individual Aggregator, LLC
Class A Common Units
Class A Common Stock
714080
714080
I
By DMI Holdco LLC
Pursuant to the Third Amended and Restated Limited Liability Company Agreement of Dutch Mafia, LLC ("Dutch Mafia"), dated September 14, 2021, Class A Common Units of Dutch Mafia, together with an equal number of shares of Class B Common Stock of the Issuer are exchangeable for shares of Class A Common Stock on a one-for-one basis at the discretion of the holder, subject to certain exceptions, conditions and adjustments. Upon such exchange, the associated shares of Class B Common Stock are surrendered and canceled by the Issuer. The Class A Common Units of Dutch Mafia and the Class B Common Stock of the Issuer do not have an expiration date and the holders thereof are not required to pay an exercise price in connection with exchanges.
Represents Class A Common Units of Dutch Mafia.
/s/ Thomas P. Conaghan, Attorney-in-Fact for Travis Boersma
2024-01-25