SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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 Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
CRACKER BARREL OLD COUNTRY STORE, INC
[ CBRL ]
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5. 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) |
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SVP, Sourcing & Supply Chain
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3. Date of Earliest Transaction
(Month/Day/Year)
09/27/2017
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4. 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 Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
Amount |
(A) or (D) |
Price |
| Common Stock |
09/27/2017 |
|
A |
|
368
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A |
$0.00
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2,221 |
D |
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
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| Remarks: |
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P Doug Couvillion by Richard M. Wolfson, Attorney-in-Fact |
09/29/2017 |
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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
4
(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
KNOW ALL MEN BY THESE PRESENTS, that the undersigned, P Doug
Couvillion, hereby appoints Jill Golder or Richard M. Wolfson, or
either of them, to be the undersigned's true and lawful attorney, for
him, and in his name, place and stead to execute, acknowledge, deliver
and file, by mail, delivery service or electronically, Forms 3, 4 and 5
(including amendments to those forms) with respect to securities of
Cracker Barrel Old Country Store, Inc. (the "Company") required to be
filed with the Securities and Exchange Commission, national securities
exchanges and the Company pursuant to Section 16(a) of the Securities
Exchange Act of 1934 and the rules and regulations under that Act,
granting to Jill Golder or Richard M. Wolfson full power and authority
to perform all acts necessary to the completion of those purposes.
The undersigned agrees that the attorney-in-fact, Jill Golder or
Richard M. Wolfson, may rely entirely on information furnished orally
or in writing by the undersigned to any specified attorney-in-fact.
The undersigned also agrees to indemnify and hold the Company and the
attorney-in-fact harmless against any losses, claims, damages or
liabilities (or actions or proceedings in these respects) that arise
out of or are based upon any untrue statements or omission of necessary
facts in the information provided by the undersigned to the attorney-
in-fact for any legal or other expenses reasonably incurred in
connection with investigating, defending against or resolving any such
loss, claim, damage, liability or action.
The validity of this Power of Attorney shall not be affected in
any manner by reason of the execution, at any time, of other powers of
attorney by the undersigned in favor of persons other than those named
in this document.
The undersigned agrees and represents to those dealing with my
attorney-in-fact, Jill Golder or Richard M. Wolfson, that this Power of
Attorney is for indefinite duration and may be voluntarily revoked by
me only by written notice to the specified attorney-in-fact, delivered
by registered mail or certified mail, return receipt requested.
WITNESS THE EXECUTION OF THIS POWER on September 18, 2017.
/s/ P Doug Couvillion
P Doug Couvillion
