| 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 11/24/2003 |
3. Issuer Name and Ticker or Trading Symbol
SIRVA INC [ SIR ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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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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| Table I - Non-Derivative Securities Beneficially Owned | |||
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| 1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
| Common Stock | 13,394,422 | I | See Note Below(1) |
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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) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
| Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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| Explanation of Responses: |
| 1. Clayton, Dubilier and Rice Fund VI Limited Partnership (Fund VI) is the owner of record of the 13,394,422 shares of Common Stock of SIRVA, Inc. reported on this Form. CD&R Associates VI Limited Partnership, a Cayman Islands exempted limited partnership (Associates VI) is the general partner of Fund VI, with the power to vote and dispose of Fund VI's shares. CD&R Investment Associates VI, Inc., a Cayman Islands exempted company (IA VI) is the managing general partner of Associates VI and has the power to direct Associates VI as to the voting and disposition of the shares held by Fund VI. No person controls the voting and dispositive power of IA VI with respect to shares owned by Fund VI. The reporting persons expressly disclaim beneficial ownership of the shares of SIRVA, except to the extent of any pecuniary interest. This report shall not be an admission that the reporting persons are the beneficial owners of such securities for purposes of Section 16 or for any other purpose. |
| CD&R Investment Associates VI, Inc., by Donald J. Gogel, its President and Chief Executive Officer | 11/24/2003 | |
| CD&R Associates VI LP, by CD&R Investment Associates VI, Inc., by Donald J. Gogel, its President and Chief Executive Officer | 11/24/2003 | |
| ** 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. | ||