SEC FORM
3
SEC Form 3
FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
TWO WARREN PLACE |
6120 SOUTH YALE AVENUE, SUITE 700 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 11/09/2010
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3. Issuer Name and Ticker or Trading Symbol
SemGroup Corp
[ SEMG ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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5. 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 Beneficially Owned |
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 |
16,217 |
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 Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
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: 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 |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of Responses: |
Remarks: |
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Candice L. Cheeseman, Power of Attorney for John F. Chlebowski |
11/09/2010 |
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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
5
(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. |
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POWER OF ATTORNEY
The undersigned hereby makes, constitutes and appoints each of Candice
L. Cheeseman,
Robert N. Fitzgerald and Deborah S. Fleming, signing singly, as the
undersigned's true and
lawful attorney-in-fact, with full power and authority as hereinafter
described on behalf of and in
the name, place and stead of the undersigned to:
(1) prepare, execute, acknowledge in the undersigned's name and on
the
undersigned's behalf, and submit to the U.S. Securities and Exchange
Commission (the "SEC") a
Form ID, including any amendments thereto, and any other documents necessary
or appropriate
to obtain codes and passwords enabling the undersigned to make electronic
filings with the SEC
of reports required by Section 16 of the Securities Exchange Act of 1934 and
the rules and
regulations promulgated thereunder, as amended from time to time (the
"Exchange Act"), or any
rule or regulation of the SEC;
(2) prepare, execute, acknowledge, deliver and file Forms 3, 4 and 5
or such other
forms, including any amendments thereto, as may be required by Section 16 of
the Exchange Act
with respect to the securities of SemGroup Corporation, a Delaware
corporation (the
"Company"), with the SEC and the Company;
(3) seek or obtain, as the undersigned's representative and on the
undersigned's
behalf, information on transactions in the Company's securities from any
third party, including
brokers, employee benefit plan administrators and trustees, and the
undersigned hereby
authorizes any such person to release any such information to the undersigned
and approves and
ratifies any such release of information; and
(4) perform any and all other acts which in the discretion of such
attorney-in-fact are
determined to be necessary or desirable for and on behalf of the undersigned
in connection with
the foregoing.
The undersigned acknowledges that:
(1) this Power of Attorney authorizes, but does not require, each
such attorney-in-fact
to act in his or her discretion on information provided to such attorney-in-
fact without
independent verification of such information;
(2) any documents prepared and/or executed by each such attorney-in-
fact on behalf
of the undersigned pursuant to this Power of Attorney will be in such form
and will contain such
information and disclosure as such attorney-in-fact, in his or her
discretion, deems necessary or
desirable;
(3) neither the Company nor such attorneys-in-fact assume(s) (i) any
liability for the
undersigned's responsibility to comply with the requirements of the Exchange
Act, (ii) any
liability of the undersigned for any failure to comply with such
requirements, or (iii) any
obligation or liability of the undersigned for profit disgorgement under
Section 16(b) of the
Exchange Act; and
(4) this Power of Attorney does not relieve the undersigned from
responsibility for
compliance with the undersigned's obligations under the Exchange Act,
including without
limitation the reporting requirements under Section 16 of the Exchange Act.
The undersigned hereby gives and grants to each such attorney-in-fact
full power and
authority to do and perform all and every act and thing whatsoever requisite,
necessary or
appropriate to be done in and about the foregoing matters as fully to all
intents and purposes as
the undersigned might or could do if present, hereby ratifying all that such
attorney-in-fact of,
for and on behalf of the undersigned, shall lawfully do or cause to be done
by virtue of this
Power of Attorney.
This Power of Attorney shall remain in full force and effect until
revoked by the
undersigned in a signed writing delivered to such attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be
executed as of this 16th day of September, 2010.
/s/ John F. Chlebowski, Jr.
John F. Chlebowski, Jr.
STATE OF OKLAHOMA )
) ss.
COUNTY OF TULSA )
On this 16th day of September, in the year 2010, before me, the undersigned,
a Notary Public in
and for said state, personally appeared John F. Chlebowski, Jr., personally
known to me or
proved to me on the basis of satisfactory evidence to be the person whose
name is subscribed to
the within instrument and acknowledged to me that he/she executed the same in
his/her capacity,
and that by his/her signature on the instrument, the person or the entity
upon behalf of which the
person acted, executed the instrument.
/s/ Stacey B. Hostetler
Notary Public
(SEAL)
My Commission Expires: 6/25/2011