Statement of Changes in Beneficial Ownership (4)
September 18 2018 - 6:57PM
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
Estimated average burden
hours per response...
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
*
Yorktown XI Associates LLC
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2. Issuer Name
and
Ticker or Trading Symbol
Carbon Energy Corp
[
CRBO
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
C/O YORKTOWN PARTNERS LLC, 410 PARK AVENUE, 19TH FLOOR
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3. Date of Earliest Transaction
(MM/DD/YYYY)
11/1/2017
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(Street)
NEW YORK, NY 10022
(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, par value $0.01 per share
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11/1/2017
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M
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432051
(1)
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A
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(2)
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432051
(3)
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I
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See Footnotes
(4)
(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 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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Warrant
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(2)
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11/1/2017
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M
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432051
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4/3/2017
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4/3/2024
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Common Stock, par value $0.01 per share
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432051
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(2)
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0
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I
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See Footnotes
(4)
(5)
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Explanation of Responses:
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(1)
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Shares received upon exercise of Warrant No. 2, issued on April 3, 2017 (the "CAC Warrant") to Yorktown Energy Partners XI, L.P. ("Yorktown XI").
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(2)
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The consideration Yorktown XI paid for the full exercise of the CAC Warrant was the transfer and assignment to Carbon Natural Gas Company (the "Issuer") of 2,940 Class A Units of Carbon Appalachian Company, LLC, a Delaware limited liability company.
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(3)
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These shares were inadvertently omitted from one Form 4 filed by the reporting person on April 9, 2018.
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(4)
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These securities are directly owned by Yorktown XI. The reporting person is the sole general partner of Yorktown XI Company LP, the sole general partner of Yorktown XI.
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(5)
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The reporting person disclaims beneficial ownership of these securities except to the extent of its pecuniary interest therein, and this report shall not be deemed an admission that the reporting person is the beneficial owner of the securities for Section 16 or any other purpose.
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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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Yorktown XI Associates LLC
C/O YORKTOWN PARTNERS LLC
410 PARK AVENUE, 19TH FLOOR
NEW YORK, NY 10022
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X
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Signatures
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Yorktown XI Associates LLC, /s/ Peter A. Leidel, Manager
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9/18/2018
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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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