- Initial Statement of Beneficial Ownership (3)
May 08 2012 - 7:14PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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, 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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1. Name and Address of Reporting Person
*
Chernicky David James
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2. Date of Event Requiring Statement (MM/DD/YYYY)
5/8/2012
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3. Issuer Name
and
Ticker or Trading Symbol
New Source Energy Corp [NSE]
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(Last)
(First)
(Middle)
914 N. BROADWAY AVENUE, SUITE 230
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__
X
__ Director
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X
___ 10% Owner
___
X
___ Officer (give title below)
_____ Other (specify below)
Chair. of Bd. & Sr. Geologist /
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(Street)
OKLAHOMA CITY, OK 73102
(City)
(State)
(Zip)
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5. 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 Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common Stock
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168300
(1)
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D
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Common Stock
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20000000
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I
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By David J. Chernicky Trust
(2)
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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. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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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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(1) This amount represents 200,000 shares of restricted common stock granted to the reporting person, of which 100,000 shares are scheduled to vest on August 18, 2012, and 100,000 shares are scheduled to vest on the completion of the initial public offering of the Issuer, provided the reporting person remains employed by the Issuer on the applicable vesting dates, subject to limited exceptions. Of the 100,000 shares scheduled to vest upon completion of the Issuer's initial public offering, the amount further reflects the surrender of 31,700 of such shares in order to pay certain tax withholding obligations incurred on such vesting, pursuant to an election previously submitted by the reporting person.
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(
2)
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Shares owned by the David J. Chernicky Trust, of which David J. Chernicky is the sole beneficiary and sole trustee.
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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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Chernicky David James
914 N. BROADWAY AVENUE, SUITE 230
OKLAHOMA CITY, OK 73102
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X
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X
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Chair. of Bd. & Sr. Geologist
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Signatures
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David J. Chernicky
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5/8/2012
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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 5(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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