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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1. Name and Address of Reporting Person*
Ma Adrianna

(Last) (First) (Middle)
1401 LAWRENCE ST, SUITE 1800

(Street)
DENVER CO 80202

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
07/23/2019
3. Issuer Name and Ticker or Trading Symbol
Jagged Peak Energy Inc. [ JAG ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
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)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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:
No securities are beneficially owned.
/s/ Christopher I. Humber, Attorney-in-Fact 07/25/2019
** 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.
POWER OF ATTORNEY

FOR EXECUTING FORMS 3, FORMS 4, FORMS 5 AND FORM 144

The undersigned hereby constitutes and appoints Robert W. Howard, Christopher
I. Humber and Shonn Stahlecker or any of them acting without the other, with
full power of substitution, as the undersigned?s true and lawful
attorney-in-fact to:
1. prepare, execute 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 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(a)
of the Securities Exchange Act of 1934, as amended (the ?Exchange Act?) or
any rule or regulation of the SEC;
2. execute for and on behalf of the undersigned any Form 3, Form 4,
Form 5 and Form 144 (including any amendments, corrections, supplements or
other changes thereto) in accordance with Section 16(a) of the Exchange Act,
and the rules thereunder, but only to the extent each form or schedule relates
to the undersigned?s beneficial ownership of securities of Jagged Peak Energy
Inc. or any of its subsidiaries;
3. do and perform any and all acts for and on behalf of the undersigned that
may be necessary or desirable to complete and execute any Form 3, Form 4,
Form 5 or Form 144 (including any amendments, corrections, supplements or
other changes thereto) and timely file the forms or schedules with the SEC
and any stock exchange or quotation system, self-regulatory association or
any other authority, and provide a copy as required by law or advisable to
such persons as the attorney-in-fact deems appropriate; and
4. take any other action in connection with the foregoing that, in the opinion
of the attorney-in-fact, may be of benefit to, in the best interest of
or legally required of the undersigned, it being understood that the documents
executed by the attorney-in-fact on behalf of the undersigned pursuant to this
Power of Attorney shall be in the form and shall contain the terms and
conditions as the attorney-in-fact may approve in the attorney-in-fact?s
discretion.

The undersigned hereby grants to the attorney-in-fact full power and authority
to do and perform all and every act requisite, necessary or proper to be done
in the exercise of any of the rights and powers herein granted, as fully to
all intents and purposes as the undersigned might or could do if personally
present, with full power of substitution or revocation, hereby ratifying and
confirming all that the attorney-in-fact shall lawfully do or cause to be
done by virtue of this Power of Attorney and the rights and powers granted
herein.  The undersigned acknowledges that the attorneys-in-fact, in serving
in such capacity at the request of the undersigned, are not assuming (nor
is Jagged Peak Energy Inc. assuming) any of the undersigned?s
responsibilities to comply with Section 16 of the Exchange Act. The undersigned
agrees that the attorney-in-fact may rely entirely on information furnished
orally or in writing by or at the direction of the undersigned to the
attorney-in-fact.  The undersigned also agrees to indemnify and hold harmless
Jagged Peak Energy Inc. and the attorney-in-fact against any losses, claims,
damages or liabilities (or actions in these respects) that arise out of or
are based upon any untrue statements or omissions of necessary facts in
the information provided by or at the direction of the undersigned, or upon
the lack of timeliness in the delivery of information by or at the direction
of the undersigned, to the attorney-in fact for purposes of executing,
acknowledging, delivering or filing a Form 3, Form 4, Form 5 or Form 144
(including any amendments, corrections, supplements or other changes thereto)
with respect to the undersigned?s holdings of and transactions in securities
issued by Jagged Peak Energy Inc., and agrees to reimburse Jagged Peak
Energy Inc. and the attorney-in-fact on demand for any legal or other
expenses reasonably incurred in connection with investigating or defending
against any such loss, claim, damage, liability or action.
This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Form 3, Form 4, Form 5 and Form 144
(including any amendments, corrections, supplements or other changes thereto)
with respect to the undersigned?s holdings of and transactions in securities
issued by Jagged Peak Energy Inc., unless earlier revoked by the undersigned
in a signed writing delivered to the attorney-in-fact. This Power of Attorney
does not revoke any other power of attorney that the undersigned has
previously granted.

[Signature page follows.]

IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of the date written below.
?
/s/ Adrianna Ma
Signature
?
Adrianna Ma
Type or Print Name

7/25/2019
Date


Signature Page to Power of Attorney