Origin Bancorp : Initial filing by director officer or owner of more than ten percent.

SEC Form 3

FORM 3

UNITED STATES SECURITIES AND EXCHANGE COMMISSION

OMB APPROVAL

Washington, D.C. 20549

OMB Number:

3235-0104

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF

Estimated average burden

hours per response:

0.5

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

1. Name and Address of Reporting Person *

2. Date of Event Requiring

3. Issuer Name and Ticker or Trading Symbol

GOFF STACEY W

(Month/Day/Year)

Origin Bancorp, Inc.[ OBNK ]

Statement

12/04/2019

4. Relationship of Reporting Person(s) to Issuer

5. If Amendment, Date of Original Filed

(Last)

(First)

(Middle)

(Check all applicable)

(Month/Day/Year)

500 SOUTH SERVICE ROAD EAST

X Director

10% Owner

6. Individual or Joint/Group Filing (Check

Officer (give title

Other (specify

Applicable Line)

below)

below)

X Form filed by One Reporting Person

(Street)

Form filed by More than One

RUSTON

LA

71270

Reporting Person

(City)

(State)

(Zip)

Table I - Non-Derivative Securities Beneficially Owned

1. Title of Security (Instr. 4)

2. Amount of Securities

3. Ownership

4. Nature of Indirect Beneficial Ownership

Beneficially Owned (Instr. 4)

Form: Direct (D)

(Instr. 5)

or Indirect (I)

(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

3. Title and Amount of Securities

4.

5.

6. Nature of Indirect

Expiration Date

Underlying Derivative Security (Instr. 4)

Conversion

Ownership

Beneficial Ownership

(Month/Day/Year)

or Exercise

Form:

(Instr. 5)

Price of

Direct (D)

Amount

Derivative

or Indirect

or

Security

(I) (Instr. 5)

Number

Date

Expiration

of

Exercisable

Date

Title

Shares

Explanation of Responses:

Remarks:

No securities are beneficially owned.

/s/ Drake Mills, as Attorney-in-

12/11/2019

Fact

** 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.

LIMITED POWER OF ATTORNEY

The undersigned, Stacey W. Goff, a director nominee of Origin Bancorp, Inc. (the "Corporation"), hereby authorizes and designates each of Drake Mills; Jim Crotwell; and Fenimore, Kay, Harrison and Ford,

1. prepare and sign on my behalf any Form ID for filing with the United States Securities and Exchange Commission, generate or update on my behalf any applicable EDGAR access codes, and request on m
2. prepare and sign on my behalf any Form 3, Form 4 or Form 5 under Section 16 of the Securities Exchange Act of 1934 or any amendment thereto and file, or cause to be filed, the same with the Unite
3. prepare and sign on my behalf any Form 144 Notice under the Securities Act of 1933, or any amendment thereto, and file, or cause to be filed, the same with the United States Securities and Exchan
4. prepare and sign on my behalf any Schedule 13D or Schedule 13G under the Securities Exchange Act of 1934, or any amendment thereto, and file, or cause to be filed, the same with the United States
5. 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 hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary or proper to be done in the exercise of This Limited Power of Attorney shall remain in full force and effect until the undersigned is no longer subject to Section 16 of the Securities Exchange Act of 1934 with respect to the Corporation, unle

IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to be executed on this 10th day of December, 2019.

By: /s/ Stacey W. Goff

Name: Stacey W. Goff