- Statement of Changes in Beneficial Ownership (4)
January 02 2013 - 7:13PM
Edgar (US Regulatory)
FORM 4
[ ]
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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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
*
HAUGEN ROBERT W
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2. Issuer Name
and
Ticker or Trading Symbol
CVR ENERGY INC
[
CVI
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
EVP, Refining Operations
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(Last)
(First)
(Middle)
C/O CVR ENERGY, INC., 2277 PLAZA DRIVE, SUITE 500
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3. Date of Earliest Transaction
(MM/DD/YYYY)
5/4/2012
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(Street)
SUGAR LAND, TX 77479
(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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5/4/2012
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D
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43095
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D
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(1)
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0
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D
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Common Stock
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12/30/2012
(8)
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M
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8810
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A
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$30
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8810
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D
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Common Stock
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12/30/2012
(8)
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D
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8810
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D
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$30
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0
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D
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Commons Stock
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12/31/2012
(8)
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M
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5435
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A
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$30
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5435
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D
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Common Stock
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12/31/2012
(8)
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D
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5435
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D
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$30
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0
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D
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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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Restricted Stock Units
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(2)
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5/4/2012
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A
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43095
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(3)
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(4)
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Common Stock
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43095
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$0
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43095
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D
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Restricted Stock Units
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(5)
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12/28/2012
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A
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11536
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(6)
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(7)
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Common Stock
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11536
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$0
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54631
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D
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Restricted Stock Units
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(8)
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12/30/2012
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M
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8810
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12/30/2012
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12/30/2012
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Common Stock
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8810
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$30
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45821
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D
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Restricted Stock Units
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(8)
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12/31/2012
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M
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5435
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12/31/2012
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12/31/2012
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Common Stock
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5435
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$30
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40386
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D
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Explanation of Responses:
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(
1)
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Although initially reported as Common Stock, these shares were converted into Restricted Stock Units effective as of May 4, 2012 in connection with the Transaction Agreement dated April 18, 2012 entered into among CVR Energy, Inc. and certain affiliates of Carl C. Icahn. Therefore, the number of shares formerly held by the reporting person as Restricted Stock was disposed to the company, and Table II depicts replacement with the acquisition of an equal number of Restricted Stock Units.
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(
2)
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Each Restricted Stock Unit reported herein represents the right to receive upon vesting, a cash payment equal to the lesser of $30 or the fair market value of one share of common stock of the company as of the vesting date, plus the CCP Consideration, as defined in the Transaction Agreement.
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(
3)
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The Restricted Stock Units vest in three annual installments in accordance with the terms provided in the replacement award agreement for the awards originally dated July 16, 2010, December 31, 2010 and December 30, 2011.
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(
4)
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The Restricted Stock Units expire immediately following payment within 10 days after their vesting.
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(
5)
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Each Restricted Stock Unit reported herein represents the right to receive upon vesting, a cash payment equal to the fair market value of one share of common stock of the company as of the vesting date.
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(
6)
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The Restricted Stock Units awarded to the reporting person vest in three annual installments beginning on December 28, 2013.
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(
7)
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The Restricted Stock Units expire immediately following their vesting in three equal installments beginning on December 28, 2013.
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(
8)
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This transaction represents the settlement of vested Restricted Stock Units in cash by the company.
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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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HAUGEN ROBERT W
C/O CVR ENERGY, INC.
2277 PLAZA DRIVE, SUITE 500
SUGAR LAND, TX 77479
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EVP, Refining Operations
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Signatures
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/s/ Edmund S. Gross, Attorney-in-fact
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1/2/2013
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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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