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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN 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 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
BALLSCHMIEDE RONALD A 6120 SOUTH YALE AVE. SUITE 700 TULSA, OK 74136 |
X |
Candice L. Cheeseman, Power of Attorney for Ronald A. Ballschmiede | 09/30/2016 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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). |
(1) | On September 30, 2016, pursuant to an Agreement and Plan of Merger entered into by Rose Rock Midstream, L.P. ("RRMS"), Rose Rock Midstream GP, LLC, SemGroup Corporation ("SemGroup"), and PBMS, LLC, each outstanding common unit representing limited partner interests in RRMS (each a "Common Unit") held by the Reporting Person converted into 0.8136 shares of validly issued, fully paid and non-assessable SemGroup Class A common stock, par value $0.01 per share (the "Merger Exchange"). As a result of the Merger Exchange, SemGroup issued the common stock reported on Table 1 to the Reporting Person. |
(2) | 15,358 shares previously reports as directly owned are now being reports as indirectly owned by the RAB GRAT 2016-1 grantor annuity trust ("GRAT"). The reporting person is the sole trustee and sole annuitant of the GRAT. |