SEC FORM
3
SEC Form 3
FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 05/31/2007
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3. Issuer Name and Ticker or Trading Symbol
JAZZ PHARMACEUTICALS INC
[ JAZZ ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
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Officer (give title below) |
X |
Other (specify below) |
X See Footnotes (2)(3)&(4) |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Form filed by One Reporting Person |
X |
Form filed by More than One Reporting Person |
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Table I - Non-Derivative Securities Beneficially Owned |
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 Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
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: 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 |
Expiration Date |
Title |
Amount or Number of Shares |
Series B Prime Preferred Stock |
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Common Stock |
8,614,419 |
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I |
See Footnotes
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Series BB Preferred Stock Warrant (right to buy) |
06/24/2005 |
06/24/2012 |
Series BB Preferred Stock |
245,540 |
20.36 |
I |
See Footnotes
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
|
1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
|
1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
2800 SAND HILL ROAD, SUITE 200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
2800 SAND HILL ROAD, SUITE 200 |
(Street)
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Explanation of Responses: |
Remarks: |
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/s/ William J. Janetschek, Secretary for KKR JP LLC |
05/31/2007 |
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/s/ William J. Janetschek, Secretary for KKR JP III LLC |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for Henry R. Kravis, Managing Member for KKR III GP LLC |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for Henry R. Kravis, Managing Member, KKR Millennium GP LLC General Partner for KKR ASSOCIATES MILLENNIUM L.P. |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for Henry R. Kravis, Managing Member, KKR III GP LLC General Partner for KKR PARTNERS III, L.P. |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for Henry R. Kravis, Managing Member, KKR Millennium GP LLC General Partner for KKR Associates Millennium L.P General Partner for KKR MILLENNIUM FUND L.P. |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for Henry R. Kravis, Managing Member for KKR MILLENNIUM GP LLC |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for Henry R. Kravis |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for George R. Roberts |
05/31/2007 |
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/s/ William J. Janetschek, as attorney-in-fact for James H. Greene, Jr. |
05/31/2007 |
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** Signature of Reporting Person |
Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
* If the form is filed by more than one reporting person,
see
Instruction
5
(b)(v). |
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
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 Number. |
rrd142033_160408.html
POWER OF ATTORNEY
Know all men by these presents that Henry R. Kravis does hereby make, constitute and
appoint William J. Janetschek and Richard J. Kreider, or either one of them, as a true and
lawful attorney-in-fact of the undersigned with full powers of substitution and revocation,
for and in the name, place and stead of the undersigned (both in the undersigned's
individual capacity and as a member of any limited liability company or as a partner of
any partnership for which the undersigned is otherwise authorized to sign), to execute and
deliver such forms as may be required to be filed from time to time with the Securities
and Exchange Commission with respect to: (i) Sections 13(d) and 16(a) of the Securities
Exchange Act of 1934, as amended (the "Act"), including without limitation, Schedule
13D, Schedule 13G, statements on Form 3, Form 4 and Form 5 and (ii) in connection
with any applications for EDGAR access codes, including without limitation the Form
ID.
/s/ Henry R. Kravis
Name: Henry R. Kravis
Date: July 31, 2005
rrd142033_160412.html
POWER OF ATTORNEY
Know all men by these presents that George R. Roberts does hereby make, constitute and
appoint William J. Janetschek and Richard J. Kreider, or either one of them, as a true and
lawful attorney-in-fact of the undersigned with full powers of substitution and revocation,
for and in the name, place and stead of the undersigned (both in the undersigned's
individual capacity and as a member of any limited liability company or as a partner of
any partnership for which the undersigned is otherwise authorized to sign), to execute and
deliver such forms as may be required to be filed from time to time with the Securities
and Exchange Commission with respect to: (i) Sections 13(d) and 16(a) of the Securities
Exchange Act of 1934, as amended (the "Act"), including without limitation, Schedule
13D, Schedule 13G, statements on Form 3, Form 4 and Form 5 and (ii) in connection
with any applications for EDGAR access codes, including without limitation the Form
ID.
/s/ George R. Roberts
Name: George R. Roberts
Date: July 31, 2005
rrd142033_160413.html
POWER OF ATTORNEY
Know all men by these presents that James H. Greene, Jr. does hereby make, constitute
and appoint William J. Janetschek and Richard J. Kreider, or either one of them, as a true
and lawful attorney-in-fact of the undersigned with full powers of substitution and
revocation, for and in the name, place and stead of the undersigned (both in the
undersigned's individual capacity and as a member of any limited liability company or as
a partner of any partnership for which the undersigned is otherwise authorized to sign), to
execute and deliver such forms as may be required to be filed from time to time with the
Securities and Exchange Commission with respect to: (i) Sections 13(d) and 16(a) of the
Securities Exchange Act of 1934, as amended (the "Act"), including without limitation,
Schedule 13D, Schedule 13G, statements on Form 3, Form 4 and Form 5 and (ii) in
connection with any applications for EDGAR access codes, including without limitation
the Form ID.
/s/ James H. Greene, Jr.
Name: James H. Greene, Jr.
Date: July 31, 2005