Form 3 SHOE CARNIVAL INC For: Sep 16 Filed by: Randolph Diane
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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 |
Expires: |
December 31, 2014 |
Estimated average burden |
hours per response: |
0.5 |
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1. Name and Address of Reporting Person
*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 09/16/2021
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3. Issuer Name
and
Ticker or Trading Symbol
SHOE CARNIVAL INC
[
SCVL
]
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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 |
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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)
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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)
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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 beneficially owned.Exhibit List: Exhibit 24-Power of Attorney |
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By: W. Kerry Jackson For: Diane Randolph, power of attorney filed herewith |
09/20/2021 |
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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
For Executing Forms 3, 4, 5 and 144
The undersigned hereby appoints each of Mark J. Worden, W. Kerry
Jackson and Patrick C. Edwards, signing singly, as her true and
lawful attorney-in-fact, for such period of time that the undersigned
is required to file reports pursuant to Section 16(a) of the
Securities Exchange Act of 1934, as amended (the "Exchange Act"), or
Rule 144 of the Securities Act of 1933, as amended (the "Securities
Act"), due to her affiliation with Shoe Carnival, Inc., an Indiana
corporation, unless earlier revoked by the undersigned in a signed
writing delivered to the foregoing attorneys-in-fact, to:
(1) execute for and on behalf of the undersigned Forms 3, 4, 5 and 144
and any amendments to previously filed forms in accordance with
Section 16(a) of the Exchange Act or Rule 144 of the Securities Act
and the rules thereunder;
(2) do and perform any and all acts for and on behalf of the
undersigned which may be necessary or desirable to complete the
execution of any Forms 3, 4, 5 and 144 and the timely filing of such
form with the United States Securities and Exchange Commission and
any other authority as required by law; and
(3) take any other action of any type whatsoever in connection with
the foregoing which, in the opinion of such attorney-in-fact, may be
of benefit to, in the best interest of, or legally required by, the
undersigned, it being understood that the documents executed by such
attorney-in-fact on behalf of the undersigned pursuant to this Power
of Attorney shall be in such form and shall contain such terms and
conditions as such attorney-in-fact may approve in his discretion.
The undersigned hereby grants to each such attorney-in-fact full power
and authority to do and perform all and every act and thing
whatsoever requisite, necessary and proper to be done in the exercise
of any of the rights and powers herein granted, as fully to all
intents and purposes as the undersigned could do if personally
present, with full power of substitution or revocation, hereby
ratifying and confirming all that such attorney-in-fact, or his
substitute or substitutes, shall lawfully do or cause to be done by
virtue of this Power of Attorney and the rights and powers herein
granted. The undersigned acknowledges that the foregoing attorneys-
in-fact, in serving in such capacity at the request of the
undersigned, are not assuming any of the undersigned's
responsibilities to comply with Section 16 of the Exchange Act or Rule
144 of the Securities Act.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of this 10th day of September, 2021.
/s/ Diane Randolph