UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 |
|
| ||||||||||||||||||||||||||||||
|
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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. |
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 of Derivative Security: 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 |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Quinonez Miguel Angel C/O XERIUM TECHNOLOGIES, INC. ONE TECHNOLOGY DRIVE WESTBOROUGH, MA 01581 |
 |  |  President-Clothing Americas |  |
/S/ Milap Patel, by power of attorney | 05/10/2005 | |
**Signature of Reporting Person | Date |
No securities are beneficially owned | |
* | 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). |
 Remarks: As of the date hereof, the Reporting Person does not beneficially own any securities of the Issuer. Immediately prior to the Issuer's contemplated initial public offering (the "Offering") described in Amendment No. 11 to the Issuer's Registration Statement on Form S-1 filed with the Securities and Exchange Commission on May 10, 2005 (the "Registration Statement"), pursuant to an Exchange and Redemption Agreement by and among the Issuer and the Reporting Person, as described in the Registration Statement, and assuming an initial public officering price of $15.00, which represents the mid-point of the range set forth in the Registration Statement, the Reporting Person will transfer his equity interest in Xerium S.A., the indirect parent of the Issuer prior to the Offering, to the Issuer in exchange for 245,226 shares of the Issuer's Common Stock. |