SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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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| OMB APPROVAL |
| OMB Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
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|
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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). |
1. Name and Address of Reporting Person*
| 500 WEST TEXAS AVENUE, SUITE 1200 |
|
(Street)
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2. Issuer Name and Ticker or Trading Symbol
RATTLER MIDSTREAM LP
[ RTLR ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| President |
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3. Date of Earliest Transaction
(Month/Day/Year)
05/28/2019
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction 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 |
V |
Amount |
(A) or (D) |
Price |
| Common units representing limited partner interests |
05/28/2019 |
|
A
|
|
1,142,857
|
A |
$0.00
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1,142,857 |
D |
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction 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
(Month/Day/Year) |
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: Direct (D) or Indirect (I) (Instr.
4)
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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 |
| Explanation of Responses: |
|
| Remarks: |
|
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/s/ Teresa L. Dick as attorney-in-fact for Matthew Kaes Van't Hof |
05/29/2019 |
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** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * 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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| 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 Number. |
LIMITED POWER OF ATTORNEY
May 28, 2019
Know all by these present, that I, Matthew Kaes Van't Hof, hereby
constitute and appoint each of Teresa L. Dick and P. Matt Zmigrosky as my true
and lawful attorneys-in-fact (each an "Attorney-in-Fact" and, collectively, the
"Attorneys-in-Fact"), each, individually or jointly, to:
(1) execute and deliver for and on behalf of me, in my capacity as one
or more of an officer, director or significant stockholder of
Rattler Midstream LP or any of its subsidiaries (collectively, the
"Company"), Forms 3, 4 and 5 and any amendments thereto in
accordance with Section 16(a) of the Securities Exchange Act of
1934, as amended (the "Exchange Act") and the rules and regulations
thereunder;
(2) do and perform any and all acts for and on behalf of me that may be
necessary or desirable to complete and execute any such Form 3, 4
or 5, complete and execute any amendment or amendments thereto, and
timely file the same with the United States Securities and Exchange
Commission (the "SEC") and any stock exchange or similar authority,
and provide a copy as required by law or as either such Attorney-
in-Fact deems advisable and appropriate, including, without
limitation, the filing of a Form ID or any other documents
necessary or appropriate to enable such documents to be filed
electronically with the SEC; and
(3) take any other action of any type whatsoever in connection with the
foregoing that, in the opinion of such Attorney-in-Fact, may be of
benefit to, in the best interest of, or legally required by, or
for, me, it being understood that the documents executed by such
Attorney-in-Fact on behalf of me pursuant to this Limited Power of
Attorney shall be in such form and shall contain such information
and disclosures as such Attorney-in-Fact may approve in his or her
sole discretion.
I hereby grant to the Attorneys-in-Fact full power and authority to do
and perform any and every act and thing whatsoever requisite, necessary or
proper to be done in the exercise of any of the rights and powers herein
granted, as fully to all intents and purposes as I might or could do if
personally present, with full power of substitution, resubstitution or
revocation, and I hereby ratify and confirm all that the Attorneys-in-Fact, or
their substitute or substitutes, shall lawfully do or cause to be done by virtue
of this Limited Power of Attorney and the rights and powers granted herein.
I acknowledge that the Attorneys-in-Fact, in serving in such capacity at my
request, are not assuming, nor is the Company assuming, (i) any of my
responsibilities to comply with the requirements of the Exchange Act or the
Securities Act of 1933, as amended (the "Securities Act"), or any liability for
my failure to comply with such requirements, or (ii) any obligation or liability
I incur for profit disgorgement under Section 16(b) of the Exchange Act. I
further acknowledge that this Limited Power of Attorney does not relieve me from
responsibility for compliance with my obligations under the Exchange Act or the
Securities Act.
This Limited Power of Attorney shall remain in full force and effect
until I am no longer required to file Forms 3, 4 and 5 with respect to my
holdings of and transactions in securities issued by the Company, unless earlier
revoked by me in a signed writing delivered to the Attorneys-in-Fact.
IN WITNESS WHEREOF, I have executed this Limited Power of Attorney as of
the date first written above.
/s/ Matthew Kaes Van't Hof
----------------------------------
Matthew Kaes Van't Hof
