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*
| 702 W. HAMILTON STREET |
| SUITE 203 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
06/07/2013
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3. Issuer Name and Ticker or Trading Symbol
Lehigh Gas Partners LP
[ LGP ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| Chief Accounting Officer |
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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 |
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| 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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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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| No securities are beneficially owned. |
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/s/ Michelle M. Henriquez, as Attorney-in-Fact |
06/13/2013 |
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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. |
David A. Sheaffer
702 W. Hamilton Street
Allentown, PA 18101
June 11, 2013
Securities and Exchange Commission
450 5th Street N.W.
Washington, Dc 20549
Attention: Filing Desk
RE: Lehigh Gas Partners LP (LGP)
To Whom It May Concern
As permitted by instruction 7 of Form 3, Form 4, and Form 5, I hereby authorize
Michelle Henriquez, Karen Yeakel and Frank Macerato, severally and not jointly,
to sign and file on my behalf any Forms 3, 4 or 5 that I am required to file
with respect to the securities of Lehigh Gas Partners LP.
I acknowledge that none of Michelle Henriquez, Karen Yeakel or Frank Macerato is
assuming any of my responsibilities to comply with Section 16 of the Securities
Exchange Act.
Sincerely
/s/ David A. Sheaffer
David A. Sheaffer
Sworn to and subscribed before me this 11th day of June 2013
Notary: /s/ Eileen M. Watson
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Eileen M. Watson, Notary Public
City of Allentown, County of Lehigh
My Commission Expires Jan. 23, 2017
MEMBER, PENNSYLVANIA ASSOCIATION OF NOTARIES
