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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1. Name and Address of Reporting Person*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 06/23/2016 | 3. Issuer Name and Ticker or Trading Symbol LILIS ENERGY, INC. [ LLEX ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
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) |
No securities owned(1) | 0 | D |
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. On June 23, 2016, pursuant to an Agreement and Plan of Merger, dated as of December 29, 2015 (the "Merger Agreement"), as amended on January 20, 2016, March 24, 2016 and June 22, 2016, by and among Lilis Energy, Inc. ("Issuer"), Lilis Merger Sub, Inc., a wholly owned subsidiary of Issuer ("Merger Sub"), and Brushy Resources, Inc. ("Brushy"), Merger Sub merged with and into Brushy, with Brushy continuing as the surviving entity and a wholly owned subsidiary of the Issuer (the "Merger"). This report reflects the beneficial ownership of the reporting person at the time of the consummation of the Merger and does not include any securities received by the reporting person upon the consummation of the Merger. The reporting person will file a Form 4 reflecting any ownership of the Issuer's securities in connection with the consummation of the Merger. |
Remarks: |
Exhibits: Exhibit 24.1 - Power of Attorney |
/s/ Michael Pawelek | 06/27/2016 | |
** 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. |