FORM D UNITE~ STATES SE CtJR IT IE S AND EXCHANGE COMMI SION W ash in gto n, D .C . 2 11 54 9 D~J3{o1 OMB APP ROVAL OMS Number: 3235-0076 Expires: May 31,2005 Es ti mated average burden hours per response 16.00 ORM D NOTICE OF SALE OF SECURITIES PURSUANT TO REGULATION D, SECTION 4(6), AND/OR UNIFORM LIMITED OFFERING EXEMPTION SEC USE ONLY Prefix I I Serial DATE RECEIVED I I A . BA SIC ID EN TIFICA TIO N DATA . '.: N _~ m e? ~ O ff er in g to check if this is an amendment a nd n am e h as c ha ng ed , a nd in dic ate c ha ng e.) . AFFINITY VENTURES CAPITAL FUND I, LLC, CLASS SB-5 COMMON UNITS Filing Under (Check boxtcs) th at a pp ly ): 0 Rule 504 0 Rule 505 0 Rule 506 0 Section 4(6) Type of Fi!ing:' 0 N e w F il in g 0 Amendment , -v-. • r I. . Enter the information re qu este d about the issuer Name of Issuer ( 0c he ck if this is an amendment a nd n am e h as c ha ng ed , a nd in dic ate c ha ng e.) AF FI NI TY V ENT UR ES C API TAL F UN D I , LL C Address of Principal B u si ne ss O p er at io ns ( if d if fe re n t from Executive O f fi ce s) (Number and Street, City. State, Zip Code) Telephone Number ( In clu di ng Area Code) , Address of ExecutiveOffices (Number and Street, City. State, Zip Code) 2 11 N ORT H RO BINS ON, S UI TE 21 0, O KL AH OMA C IT Y, OK 7 310 2 Telephone N il m be r' (l nc lu dr ng Area Code) 405-235-5700' ,~/ Type of Business O r ga ni za ti on o corporation', o business trust o l im i te d p ar tn er sh ip , a lr ea dy f or m ed o lim ite d p ar tn er sh ip , to be formed o other (please specify); ;limited l ia b il l1 v . . nnl'An B r ie f D e sc ri pt io n of Business J, PASS THROUGH VENTURE CAPITAL ENTI TY Month Year Actual or Estimated p ate o f I nc or po ra tio n o r O rg an iz atio n:. [{[[9] ~ I2 l Actual 0 Estimated J ur is dic ti on o f I nc or po ra ti on o r O rg an iz ati on ; (Enter two-letter U.S. Postal Service abbreviation f or S ta te : : CN for Canada: FN for other foreign jurisdiction) I!l[] GENERAL INSTRUCTIONS Federal: '_. . W ho M us t F il e; A ll i §s ue rs ma ki ng a n o ff er in g o f's ec ur itie s in reliance on an exemption under Regu ation D or Section 4(6), J7 CFR 230.501 etseq. or 15U.S.c. 77d(6). ";.., : :~.~ I Wh el l To File: A notice must-be 'filed'no later than 15 days after the first sale of securities in the offering. A notice is deemed filed with the U.S. Securities and Exchange CommissiOl; (SEC) on the earlier of the date it is received by the SEC at the address given below or, if re ce iv ed at that address after the date on which it is due, on the date it-was mailed by United States registered or certified mail to that address. W he re To Fi l e: U.~;' Se~Uriti~Sand Exchange C om m is sio n, 4 50 F if th S tr ee t. N .W ., W a sh in gto n, D.C. 2 05 49 . Cop ies Requir ed: Fjye (5 ) copies of this notice must be filed with the SEC, one of which must be manually s ig ne d. A ny c lo pie s n ot m an ua lly signed must be p ho to co pie s of the manually '~igned copy or bear typed or printed signatures. ~~ .., ' :.. ' . 1 Informat ion Required: A new filing l_ O!lst o nta in a ll in fo rm atio n re qu este d. A m en dm en ts need only report the name of the issuer and offering, a ny c ha ng es thereto, the informaiion r eq ue ste d in Part C. and any material changes from the information p re vio us ly s up plie d in Parts A and B. Part E and the Appendix n ee d not be filed with thC:SEC. '..: Fi lmg F ee: T he re is no federal fil;:ng fee. " . State: . This notice shall be,\lsed to indicate reliance 011 the Uniform L im ite d O ffe rin g E xe mp tio n (ULOE) for sales of securities in those states that have adopted are to be, or have b~en made. If a state requires the payment of a fee as a precondition to the claim for the exemption, a fce in the proper amount shall accompany this fo n n . T his notice shall be filed in the appropriate states in accordance with stat law. The Appendix' to the notice constitutes a part of " A E N T O N -- --- : -- -- -, F ailure to 1ile notice in the appropriate states w ill not result in a loss 01the lederal exemption. Conversely, failure to file the a pp ro pria te federal n otic e w ill not result in a loss 01an available sta te exemption u n le s s such exemption is p re dicta te d o n th e filing 01a 'ede:ral notice. , !, SEC 1972 (6-02) Persons who respond to the collection of information contained in this form ar'e not required to respond unless the form displays a curre lly valid OMS control number. 10f9
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8/6/2019 SEC Form D Affinity Ventures Capital Fund I SB-5
. '.: N _~ m e? ~ O ff er in g to c he ck if th is is a n a me nd me nt a nd n am e h as c ha ng ed , a nd in dic ate c ha ng e.)
. AFFINITY VENTURES CAPITAL FUND I, LLC, CLASS SB-5 COMMON UNITS
F ilin g U n de r ( Ch ec k b ox tc s) th at a pp ly ): 0 Rule 504 0 Rule 505 0 R ule 5 06 0 Sect ion 4 (6)
Type o f F i! in g: ' 0 New F il in g 0 Amendment, - v - . • r
I. . E nte r th e in fo rm atio n re qu este d a bo ut th e issu er
Name of Issuer (0c he ck if th is is a n a me nd me nt a nd n am e h as c ha ng ed , a nd in dic ate c ha ng e.)
AFFINITY VENTURES CAPITAL FUND I, LLC
Addr es s o f P ri nc ip al B u si ne ss Op er at io ns( if d if fe re n t f rom Ex ecut iv e O f fi ce s)
( Nu mb er a nd S tr ee t, C ity . S ta te , Z ip C od e) T ele ph on e N u mb er ( In clu di ng A re a C od e),
Address of E xecutiveO ffices (Number and Street, C ity. State, Zip C ode)
211 NORTH ROBINSON, SUITE 210, OKLAHOMA CITY, OK 73102
Te le ph on e N ilmbe r' (l nc lu dr ng A r ea C ode )
405-235-5700' ,~/
Type o f B u si ne ss O r gani za ti on
o corporation',
o busi n es s t ru s t
o l im i te d p ar tn er sh ip , a lr ea dy f orm ed
o lim ite d p ar tn er sh ip , to b e f or me d
o o the r (p lease spec ify );
; l im i ted l iab il l1 v . .nnl'An
B r ie f De sc ri pt io n o f B u si ne ssJ,
PASS THROUGH VENTURE CAPITAL ENTITY
M onth Year
A ctu al o r E st im ate d p ate o f I nc or po ra tio n o r O rg an iz atio n:. [{[[9] ~ I2 lActual 0 Estimated
J ur is dic ti on o f I nc or po ra ti on o r O rg an iz ati on ; ( En te r tw o- le tte r U .S . P os ta l S er vic e a bb re via tio n f or S ta te :
: CN for Canada: FN for other foreign jurisdiction) I!l[]
G E NE RA L I NS TR U CT IO N S
Federal: '_. .
Who Must File; A ll i §s ue rs ma ki ng a n o ff er in g o f's ec ur itie s in r elia nc e o n a n e xemp tio n u nd er R eg ula tio n D o r S ec tio n 4 (6 ), J 7 C FR 2 30 .5 01 e t s e q. o r 1 5 U .S .c .77d(6). ";.., : :~.~ I
Whell To File: A not ic e must-be 'file d ' no la te r th an 1 5 d ay s a fte r th e first sa le o f se cu ritie s in th e o ffe rin g. A n otic e is d ee me d file d w ith th e U .S . S ec uritie s
a nd E xc ha ng e C om m issiO l; (S EC ) o n th e e arlie r o f th e d ate it is re ce iv ed b y th e S EC a t th e a dd re ss g iv en b elo w o r, if re ce iv ed a t th at a dd re ss a fte r th e d ate o n
w hic h it is d ue , o n th e d ate it-w as m aile d b y U nite d S ta te s re giste re d o r c ertifie d m ail to th at a dd re ss.
Where To File: U .~ ;' S e~ Ur iti~ S a nd E xc ha ng e C om m is sio n, 4 50 F if th S tr ee t. N .W ., W a sh in gto n, D .C . 2 05 49 .
Copies Required: Fjye (5) c op ie s o f th is n otic e m ust b e f ile d w ith th e S EC , o ne o f w hic h m ust b e m an ua lly s ig ne d. A ny c lo pie s n ot m an ua lly s ig ne d m ust b e
p ho to co pie s o f th e m an ua lly '~ ig ne d c op y o r b ea r ty pe d o r p rin te d s ig na tu re s.~ ~ . . , ' : . . ' . 1
Information Required: A n ew filin g l_ O!lst o nta in a ll in fo rm atio n re qu este d. A m en dm en ts n ee d o nly re po rt th e n am e o f th e issu er a nd o ffe rin g, a ny c ha ng es
th er eto , t he in fo rm a iio n r eq ue ste d in P ar t C . a nd a ny m ate ria l c ha ng es f ro m th e in fo rm atio n p re vio us ly s up plie d in P ar ts A a nd B . P ar t E a nd th e A pp en dix n ee d
not be filed w ith thC:SEC. '..:
Filmg Fee: T he re is n o f ed er al f il ;:n g f ee ." .
State: .
T his n otic e s ha ll b e, \ls ed to in dic ate r elia nc e 011 th e U nifo rm L im ite d O ffe rin g E xe mp tio n (U LO E) fo r sa le s o f se cu ritie s in th ose sta te s th at h av e a do pte d
U LO E and that have adopte d this form . Issuers relyin g on lJL OE m ust tile a separate n otice w ith the Securities A dm inistrator in each state w here sales
are to be, or have b~en m ade. If a state requires the paym ent of a fee as a precondition to the claim for the exem ption, a fce in the proper am ount shall
accom pan y this fon n . T his no tice shall be filed in the appropriate states in ac cordance w ith state law . T he A ppend ix' to the notice constitutes a p art of
th is n otic e a nd m u s,t b e c om ple te d.
" ATENTON--------:---------,
F ailu re to 1ile no tice in the approp ria te states w ill not resu lt in a loss 01 the lederal exem ption. C onverse ly, failure to file the
a pp ro pria te fed eral n otic e w ill no t re sult in a loss 01 a n a vaila ble sta te exe mp tion un less suc h ex em ptio n is p re dicta te d o n th e
filin g 0 1 a 'e de :ra l n otic e.
,!,
SEC 1972 (6-02)Persons who respond to the collection of information contained in this form ar'e notrequired to respond unless the form displays a curren lly valid OMS control number. 10f9
8/6/2019 SEC Form D Affinity Ventures Capital Fund I SB-5
2. Enter the infomi~lion requested for the following:
• Each promoter of the issuer, if the issuer ha~ b~e~.o~~anized within the past five years;
• Each beneficial owner having the power to vote or dispose, or direct the vote or disposition of, 10% or more of a class of equity secur ities of the issuer .
i• Each executive officer and director of corpor~te issuers and of corporate general and managing partners of partnership issuers; and
• Each general and managing partner of partnership issuers.
Check Box(cs) that Apply: e I .General and/orManaging Partnero
Promoter
oBeneficial Owner
0Executive Officer
0Director
Full Name (Last name. first, if individual)
AFFINITY VENTURES, lLC
Business or Residence Address (Number and Street, City, State, Zip Code)
211 NORTH ROB[NSON, SUITE 210, OKLAHOMA CITY, OK 73102
Check Rox(es) that A'pply: III Beneficial Owner 0 Executive Officer 0 Director o I General andlor, Managing Partner
o Promoter
Ful l Name (Last name first , if individual)
BENEVOLENT HOLDINGS CORPORATION
Business or Residence Address (Number and Street, City, State, Zip Code)
211 NORTH ROBINSON, SUITE 210, OKLAHOMA CITY, OK 73102
Check Box(es) that Apply: o Promoter o i General andlor
Managing Partner
o Beneficial Owner ~ Executive Officer 0 Director
Full Name (Last nam~ first , i f individual)
MCDONALD, ROBERT 0,
Business or Residence Address (Number and Street, City, State, Zip Code)
211 NORTH ROBI",SON, SUITE 210, OKLAHOMA CITY, OK 73102
Check Box(es) that Apply:,<
o Beneficial Owner 0 Executive Officer 0 Director 0 : General.and/orI Managtng Partner
o Promoter
Ful l Name (Last name first , if individual),<
RADER, ROBERT!G,"
Business or Residence Address (Number and Street, City, State, Zip Code)
211 NORTH ROB:INSON, SUITE 210, OKLAHOMA CITY, OK 73102
Check Box(es) that Apply: o· Beneficial Owner 0 Executive Officer 0 Director o IGeneral and/orManaging Partner
o Promoter
Ful l Name (Las! name first , if individual)
HARGIS, JERRI 't .
Business or Residence Address (Number and Street, City, State, Zip Code)
211 NORTH ROB!,NSON, SUITE 210, OKLAHOMA CITY, OK 73102
Check Box( es) that Apply: o Beneficial Owner 0 Executive Officer 0 Director D·General andlorManaging Partner
o Promoter
Full Name (Last name first, if individual)
Business or Residence Address (Number and Street, City, State, Zip Code)
Check Box(es) that Apply: o i General and/orI Managi ng Partner
o Promoter o Beneficial Owner 0 Executive Officer 0 Director
Full Name (Last name first, if individual)
Business or Residence Address (Number and Street, City, Stale, Zip Code)
(Use blank sheet, or copy and use additional copies of this sheet, as necessary)
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8/6/2019 SEC Form D Affinity Ventures Capital Fund I SB-5
I. Has the issuer sold, or does the issuer intend to sell, to non-accredited investors in this offering? ,,",', .. , .
Answer also in Appendix, Column 2, if filing undcr ULOE.I
2. What is the minimum investment that will be accepted from any individual? .
"3. Does the offeri~g permit joint ownership of a single unit? ...4. Enter the information requested for each person who has been or will be: paid or given, directly or indirectly, any
com mission or sim ilar rem uneration for solicitation of purchasers in connection with sales of securities in the loffering.
If a person to b~ listed is an associated person or agent of a broker or dealer registered with the SEC and/or with IIstate
or states. list the name of the broker or dealer. If'more than five (5) persons to be: l isted are associated person's of such
a broker or dealer, you may set forth the information for that broker or dealer only._l."
Full N am e (Last nam e first. if individual)
CAPITAL WEST ~ECURITIES, INC.
Business or Residence Address (Number and Street, City, State, Zip Code)
211 NORTH ROBINSON, SUITE 200, OKLAHOMA CITY, OK 73102
Name of Associated Broker or Dealer
. ~
States in Which Person Listed Has Solicited or Inlends to Solicit Purchasers
(Check "Al l Stat es " o r check ind iv idual Stat es ) . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
DA ll S ta te s
. I
IALI IAK.:I IAZI IARI ICAI Icol IcT! 10EI loci IFLIilGAI o m []TI
[ill Iscl Isol ITNI ITXI IuTi IVTI IVAI IWAI Iwvl L W J IWyl IPRI
"
Full Nam e (Last nam e first. if individual)
Business or Residence Address (Number and Street, City, State. Zip Code)
Name of Associated Broker or Dealer
States in Which Person Listed Has Solicited or Intends to Solicit Purchasers
(Ch eck "A ll S ta te s" o r check i nd iv id ua l S ta te s) . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. : .. .. .. .. .. .. .. . D A ll S ta te s
IALI IAKI IAZI IARI ICAI Icol ICTI IDEI loci IFLI IIGAI o m [Jill
[KJ IIN'I O A J [K[] IKYI ILAI IMEI IMDI IMAI [MIJ IMNI IMSI IMOI
h. Enter the difference between the aggregate offering price given in response to Part C - Question I
and total expenses furnished in response to Part C - Question 4.a. This difference isthe "adjusted gross
proceeds to the issuer." .
5. Indicate below the amount of the adjusted gross proceed to the issuer used or proposed to be used for
each of the purposes shown. If the amount for any purpose is not known, furnish an estimate and
check the box to' the left of the est imate. The total of the payments listed must equal the adjusted gross
proceeds to the issuer set forth in response to Part C - Question 4.b above.
s 360,000.00
Payments to
Officers,
Directors, &
Affiliates
Salaries and fe~s 0$~_~ __
Purchase of real estate · ·..·· ·· ··0$_...,...- _
Purchase, rental or leasing and installation of machinery
and equipment ·············.·.··.·.·..0$ _
Construction or leasing of plant buildings and facilities 0$_-,- _
Acquisition of other businesses (including the value of securities involved in this
offering that may be used in exchange for the assets or securities of another
issuer pursuant to a merger) 0$_-,- _
Repayment of indebtedness 0$_-,- _
Working capital 0$_-'-- _
Other (specify): VENTURE CAPITAL INVESTMENTS 0$ _
Payments to
Others
0$----
0$----
0$----
0$----
0$----0$----
0$----o S 360,000.00
___ ----"'--- 0S _ D S . _
o S 360,000.00olumn Totals 0S _ O _ . O _ O _
Total Payments Listed (column totals added) .
, ,: .:,.~·.~>I~·;.
The issuer has duly caused this notice to be signed by the undersigned duly authorized person. Ifthis notice is filed under Rule 50S, the followingsignature const itutes an undertaking by the issuer to furnish to the U.S. Securit ies and Exchange Commission, upon written request of its staff.
the information furnished by the issuer to any non-accredited investor pursuant to paragraph (b)(2) of Rule 502.
Issuer (Print or Type)
AFFINITY VENTURES CAPITAL FUND I,LLC
Name of Signer (Print or Type)
ROBERT O. MCDONALD
Title of Signer (Print or Type)
PRESIDENT OF AFFINITY VENTUR
~------~------------------ATTENTIONIntentional misstatements or omissions offact constitute federal criminal violations. (See 18 U.S.C. 1001.)
S of9
8/6/2019 SEC Form D Affinity Ventures Capital Fund I SB-5