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*
| C/O MEDIAALPHA, INC. |
| 700 SOUTH FLOWER STREET, SUITE 640 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
10/28/2020
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3. Issuer Name and Ticker or Trading Symbol
MediaAlpha, Inc.
[ MAX ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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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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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: |
|
| No securities are beneficially owned. |
|
/s/ Lance Martinez, attorney-in-fact for Sweet Lara |
10/27/2020 |
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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. |
POWER OF ATTORNEY
The undersigned hereby appoints each of Lance Martinez and Tigran Sinanyan,
signing singly, his or her true and lawful attorney-in-fact to:
1. apply for and obtain on behalf of the undersigned the necessary
access codes to file Forms 3, 4, 5 and 144, pursuant to Section
16(a) of the Securities Exchange Act of 1934 and Rule 144 of the
Securities Act of 1933, respectively, electronically via the EDGAR
system pursuant to Regulation S-T and the rules thereunder, and
2. act in a filing agent capacity to perform any and all acts for and
on behalf of the undersigned which may be necessary to complete
the filing of any such Form 3, 4, 5 and 144 with the U.S.
Securities and Exchange Commission and any other authority in
accordance with Section 16(a) of the Securities Exchange Act of
1934 and the rules thereunder and Rule 144 of the Securities Act
of 1933.
The undersigned hereby grants to each attorney-in-fact the full power and
authority, for the undersigned and on behalf of the undersigned, to perform all
acts necessary and proper to be done in the exercise of the rights and powers
hereby granted.
The undersigned acknowledges that the foregoing individuals are acting under
this Power of Attorney at the request of the undersigned and are not assuming
any of the undersigned's responsibilities to comply with Section 16 of the
Securities Exchange Act of 1934 or Rule 144 of the Securities Act of 1933.
Each attorney-in-fact shall be authorized to act under this Power of Attorney
only so long as such attorney-in-fact is an employee of MediaAlpha, Inc. or
until such time as this Power of Attorney has been revoked, annulled or set
aside.
IN WITNESS WHEREOF, the undersigned has executed this Power of Attorney as of
this 16th day of October, 2020.
/s/ Lara A. Sweet
----------------------------------------
Name: Lara A. Sweet
