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*
Clark Agenia

(Last) (First) (Middle)
C/O ALPINE SUMMIT ENERGY PARTNERS, INC.
3322 WEST END AVE., STE. 450

(Street)
NASHVILLE TN 37203

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
12/30/2022
3. Issuer Name and Ticker or Trading Symbol
ALPINE SUMMIT ENERGY PARTNERS, INC. [ ALPS ]
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
Deferred Share Units (1) (1) Class A Subordinate Voting Shares 59,125 (1) D
Explanation of Responses:
1. 36,517 of the deferred share units (DSUs) vest on December 14, 2022; 22,608 of the DSUs vest on June 1, 2023. The underlying Class A subordinate voting shares will not be issued to the reporting person, and the reporting person shall not have any voting or dispositive rights with respect to the underlying Class A subordinate voting shares, until termination of the reporting person's employment or services as a director of the Issuer.
Remarks:
Exhibit 24.1 Power of Attorney
/s/ Reagan Brown as attorney-in-fact for Agenia Clark 12/30/2022
** 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.