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*
| 2277 PLAZA DRIVE |
| SUITE 500 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
10/22/2007
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3. Issuer Name and Ticker or Trading Symbol
CVR ENERGY INC
[ CVI ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
|
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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 |
|
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
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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| No securities are beneficially owned |
0 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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: |
|
|
/s/ Susan M. Ball, Attorney-in-fact |
10/22/2007 |
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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. |
LIMITED POWER OF ATTORNEY
The undersigned, being an executive officer or director of CVR Energy, Inc.
(the "Corporation"), who will thereby be subject to the reporting obligations of
Section 16 of the Securities Exchange Act of 1934, as amended (the "Act"), with
respect to securities of the Corporation, hereby constitutes and appoints each
of Edmund S. Gross, James T. Rens and Susan M. Ball as the undersigned's true
and lawful attorneys-in-fact and agents to (i) obtain filing codes from the
Securities and Exchange Commission (the "SEC") so as to permit the filing of
Forms 3, 4, and 5 with the SEC by or on behalf of the undersigned pursuant to
Section 16 of the Act, and the rules and regulations promulgated thereunder, or
any successor laws and regulations, as a consequence of the undersigned's
ownership, acquisition or disposition of equity securities of the Corporation
and (ii) execute and file for and on behalf of the undersigned Forms 3, 4, and 5
with the SEC, and to perform all acts necessary in order to obtain such codes
and/or execute and file such Forms 3, 4, and 5, as applicable, as he or she, as
applicable, shall deem appropriate. The undersigned hereby ratifies and confirms
all that said attorneys-in-fact and agents shall do or cause to be done by
virtue hereof.
This Limited Power of Attorney shall remain in full force and effect until
the undersigned is no longer required to file Forms 3, 4, and 5 with respect to
the undersigned's holdings of and transactions in securities issued by the
Corporation, unless earlier revoked by the undersigned in a signed writing
delivered to the foregoing attorneys-in-fact.
This Limited Power of Attorney is executed as of June 7, 2007.
- ------------------------------------- ----------------------------------------
John J. Lipinski Christopher G. Swanberg
- ------------------------------------- ----------------------------------------
Stanley A. Riemann Wesley Clark
- ------------------------------------- ----------------------------------------
James T. Rens Scott Lebovitz
- ------------------------------------- ----------------------------------------
Edmund S. Gross George E. Matelich
- ------------------------------------- ----------------------------------------
Robert W. Haugen Stanley de J. Osborne
- ------------------------------------- ----------------------------------------
Wyatt E. Jernigan Kenneth A. Pontarelli
/s/ Mark Tomkins
- ------------------------------------- ----------------------------------------
Kevan A. Vick Mark Tomkins
