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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 07/16/2009 |
3. Issuer Name and Ticker or Trading Symbol
Kentucky USA Energy, Inc. [ KYUS.OB ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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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)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 1,600,000(1) | D | |
Common Stock | 6,400,000(2) | I | Via Saddlebrook Holdings, LLC, an entity for which Mr. Eversole has voting and investment control. |
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) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
1. Includes 80,000 shares of the Issuer's Common Stock currently held in escrow pursuant to an Indemnification Escrow Agreeement ("Escrow Agreement"), dated May 2, 2008, by and among the Reporting Person, the Escrow Agent and the Issuer. These shares shall be held in escrow until May 1, 2010 (or on such earlier date in accordance with the Escrow Agreement) to satisfy claims that may arise as a result of the Reporting Person's breach of any representations and warranties or covenants contained in that certain Agreement and Plan of Merger and Reorganization by and between the Issuer and KY USA Energy, Inc., dated May 2, 2008 (the "Merger Agreement"). |
2. Includes 320,000 shares of the Issuer's Common Stock currently held in escrow pursuant to the Escrow Agreement. These shares shall be held in escrow until May 1, 2010 (or on such earlier date in accordance with the Escrow Agreement) to satisfy claims that may arise as a result of the Reporting Person's breach of any representations and warranties or covenants contained in the Merger Agreement. |
Remarks: |
Ex. 24 Power of Attorney |
/s/ Paul C. Levites, attorney-in-fact | 07/16/2009 | |
** 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. |