UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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 control number. |
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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
STEPHENSON CC JR C/O CYPRESS ENERGY PARTNERS, L.P. 5727 S LEWIS AVENUE, SUITE 500 TULSA, OK 74105 |
 X |  |  | SEE REMARKS |
/s/ Richard Carson, Attorney-in-Fact for Charles C. Stephenson, Jr. | 01/23/2014 | |
**Signature of Reporting Person | Date |
No securities are beneficially owned | |
* | 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). |
 Remarks: The Reporting Person is a director of Cypress Energy Partners GP, LLC, the general partner of the Issuer (the "General Partner") and a director of Cypress Energy Holdings, LLC ("Cypress Holdings"). The Issuer is managed by the directors and executive officers of the General Partner. The General Partner is a wholly owned subsidiary of Cypress Holdings. Exhibit List: Exhibit 24 - Power of Attorney |