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