Sec Form 4 Filing - ERICKSON MARK @ Extraction Oil & Gas, Inc. - 2019-10-17

Every director, officer or owner of more than ten percent of a class of equity securities registered under Section 12 of the '34 Act must file with the U.S. Securities and Exchange Commission (SEC) a statement of ownership regarding such security.

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The following is an SEC EDGAR document rendered as filed.
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FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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, 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 *
ERICKSON MARK
2. Issuer Name and Ticker or Trading Symbol
Extraction Oil & Gas, Inc. [ XOG]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X __ Director _____ 10% Owner
X __ Officer (give title below) _____ Other (specify below)
Chairman and CEO
(Last)
(First)
(Middle)
370 17TH STREET, SUITE 5300
3. Date of Earliest Transaction (MM/DD/YY)
10/17/2019
(Street)
DENVER, CO80202
4. If Amendment, Date Original Filed (MM/DD/YY)
6. Individual or Joint/Group Filing (Check Applicable Line)
__ X __ Form filed by One Reporting Person
_____ Form filed by More than One Reporting Person
(City)
(State)
(Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 3. Transaction Code
(Instr. 8)
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
7. Nature of Indirect Beneficial Ownership
(Instr. 4)
Code V Amount (A) or (D) Price
COMMON STOCK 10/17/2019 F 93,787 D $ 2.32 1,520,755 D
COMMON STOCK 271,956 I By wife
COMMON STOCK 755,995 I ( 1 ) See Footnote (1)
COMMON STOCK 271,957 I ( 2 ) See Footnote (2)
COMMON STOCK 2,046,449 I ( 3 ) See Footnote (3)
COMMON STOCK 81 I ( 4 ) See Footnote (4)
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)
2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 4. Transaction Code
(Instr. 8)
5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4, and 5)
6. Date Exercisable and Expiration Date
(MM/DD/YY)
7. Title and Amount of Underlying Securities
(Instr. 3 and 4)
8. Price of Derivative Security
(Instr. 5)
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 4)
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
11. Nature of Indirect Beneficial Ownership
(Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
ERICKSON MARK
370 17TH STREET
SUITE 5300
DENVER, CO80202
X Chairman and CEO
Signatures
/s/ Eric J. Christ as Attorney-in-Fact 10/21/2019
** Signature of Reporting Person Date
Explanation of Responses:
( 1 )These shares are owned by Extraction Employee Incentive, LLC, an entity in which the reporting person owns a membership interest. The Reporting Person disclaims beneficial ownership of the securities reported herein, except to the extent of such Reporting Person's pecuniary interest therein, if any. Pursuant to Rule 16a-1(a)(4) under the Securities Exchange Act of 1934, as amended (the "Exchange Act"), this filing shall not be deemed an admission that the Reporting Person is, for purposes of Section 16 of the Exchange Act or otherwise, the beneficial owners of any equity securities in excess of their respective pecuniary interests.
( 2 )These shares are owned by JME Investment Properties 2016, LLC, of which Jane M. Erickson, Mr. Erickson's wife, holds the managing interest through her sole ownership of Class A Membership Interests in JME Investment Properties 2016, LLC. The Jane M. Erickson 2016 Grantor Retained Annuity Trust, of which Ms. Erickson is Trustee, owns a 75% non-managing interest in JME Investment Properties 2016, LLC.
( 3 )These shares are owned by MAE Investment Properties 2016, LLC, of which Mr. Erickson holds the managing interest through his sole ownership of Class A Membership Interests in MAE Investment Properties 2016, LLC. The Mark A. Erickson 2016 Grantor Retained Annuity Trust, of which Mr. Erickson is Trustee, owns a 75% non-managing interest in MAE Investment Properties 2016, LLC.
( 4 )These shares are owned by MAE Holdings 2011 LLC. MAE Holdings 2011 LLC is an entity owned by Mr. Erickson.

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.
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