- Initial Statement of Beneficial Ownership (3)
08 Août 2012 - 9:21PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
hours per response...
0.5
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
D'Addario Paul N.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
8/7/2012
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3. Issuer Name
and
Ticker or Trading Symbol
PEREGRINE SEMICONDUCTOR CORP [PSMI]
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(Last)
(First)
(Middle)
C/O PEREGRINE SEMICONDUCTOR CORPORATION, 9380 CARROLL PARK DRIVE
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Street)
SAN DIEGO, CA 92121
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Series C1 Preferred Stock
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(1)
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(1)
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Common Stock
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8378
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(1)
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I
(2)
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Palisades Non-Qualified Investors, L.P.
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Series C1 Preferred Stock
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(1)
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(1)
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Common Stock
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312070
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(1)
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I
(2)
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Palisades Qualified Investors, L.P.
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Series C1 Preferred Stock
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(1)
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(1)
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Common Stock
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1070312
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(1)
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I
(2)
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Palisades Ventures, L.P.
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Series D1 Preferred Stock
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(1)
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(1)
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Common Stock
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1017
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(1)
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I
(2)
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Palisades Non-Qualified Investors, L.P.
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Series D1 Preferred Stock
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(1)
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(1)
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Common Stock
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37908
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(1)
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I
(2)
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Palisades Qualified Investors, L.P.
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Series D1 Preferred Stock
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(1)
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(1)
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Common Stock
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130015
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(1)
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I
(2)
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Palisades Ventures, L.P.
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Explanation of Responses:
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(
1)
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Each share of Series C1 Preferred Stock and Series D1 Preferred Stock will automatically convert into one share of common stock upon the closing of the Issuer's initial public offering, and has no expiration date.
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(
2)
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Palisades Ventures Management, LLC is the general partner of Palisades Non-Qualified Investors, L.P., Palisades Qualified Investors, L.P., and Palisades Ventures, L.P. Paul N. D'Addario is the managing member of Palisades Ventures Management, LLC, disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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D'Addario Paul N.
C/O PEREGRINE SEMICONDUCTOR CORPORATION
9380 CARROLL PARK DRIVE
SAN DIEGO, CA 92121
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X
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Signatures
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/s/ Jay Biskupski as Attorney-in-fact for Paul N. D'Addario
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8/7/2012
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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 control number.
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