Statement of Changes in Beneficial Ownership (4)
October 21 2019 - 5:44PM
Edgar (US Regulatory)
FORM 4
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
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0.5
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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
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ERICKSON MARK |
2. Issuer Name and Ticker or Trading Symbol
Extraction Oil & Gas, Inc.
[
XOG
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Chairman and CEO
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(Last)
(First)
(Middle)
370 17TH STREET, SUITE 5300 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
10/17/2019
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(Street)
DENVER, CO 80202
(City)
(State)
(Zip)
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4. 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 Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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COMMON STOCK
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10/17/2019
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F
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93787
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D
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$2.32
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1520755
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D
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COMMON STOCK
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271956
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I
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By wife
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COMMON STOCK
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755995
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I (1)
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See Footnote (1)
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COMMON STOCK
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271957
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I (2)
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See Footnote (2)
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COMMON STOCK
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2046449
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I (3)
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See Footnote (3)
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COMMON STOCK
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81
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I (4)
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See Footnote (4)
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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. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code (Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4)
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8. Price of Derivative Security (Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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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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Explanation of Responses:
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(1)
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These shares are owned by Extraction Employee Incentive, LLC, an entity in which the reporting person owns a membership interest. The Reporting Person disclaims beneficial ownership of the securities reported herein, except to the extent of such Reporting Person's pecuniary interest therein, if any. Pursuant to Rule 16a-1(a)(4) under the Securities Exchange Act of 1934, as amended (the "Exchange Act"), this filing shall not be deemed an admission that the Reporting Person is, for purposes of Section 16 of the Exchange Act or otherwise, the beneficial owners of any equity securities in excess of their respective pecuniary interests.
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(2)
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These shares are owned by JME Investment Properties 2016, LLC, of which Jane M. Erickson, Mr. Erickson's wife, holds the managing interest through her sole ownership of Class A Membership Interests in JME Investment Properties 2016, LLC. The Jane M. Erickson 2016 Grantor Retained Annuity Trust, of which Ms. Erickson is Trustee, owns a 75% non-managing interest in JME Investment Properties 2016, LLC.
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(3)
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These shares are owned by MAE Investment Properties 2016, LLC, of which Mr. Erickson holds the managing interest through his sole ownership of Class A Membership Interests in MAE Investment Properties 2016, LLC. The Mark A. Erickson 2016 Grantor Retained Annuity Trust, of which Mr. Erickson is Trustee, owns a 75% non-managing interest in MAE Investment Properties 2016, LLC.
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(4)
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These shares are owned by MAE Holdings 2011 LLC. MAE Holdings 2011 LLC is an entity owned by Mr. Erickson.
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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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ERICKSON MARK 370 17TH STREET SUITE 5300 DENVER, CO 80202
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X
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Chairman and CEO
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Signatures
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/s/ Eric J. Christ as Attorney-in-Fact
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10/21/2019
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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 4(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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