Statement of Changes in Beneficial Ownership (4)
February 25 2022 - 5:16PM
Edgar (US Regulatory)
FORM 4
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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).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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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
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Trainor Gary |
2. Issuer Name and Ticker or Trading Symbol
Paymentus Holdings, Inc.
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PAY
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
18390 NE 68TH ST. |
3. Date of Earliest Transaction
(MM/DD/YYYY)
2/24/2022 |
(Street)
REDMOND, WA 98052
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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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 Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. 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
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V
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Amount
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(A) or (D)
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Price
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Class A Common Stock | 2/24/2022 | | C(1) | | 100000 | A | $0.00 | 100000 | I | See Explanation of Responses (2) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Stock Option (Right to Buy) | $0.03 | 2/24/2022 | | M | | | 100000 | (3) | 10/10/2022 | Class B Common Stock (4) | 100000 | $0.00 | 1189888 | I | See Explanation of Responses (2) |
Class B Common Stock | (4) | 2/24/2022 | | M | | 100000 | | (4) | (4) | Class A Common Stock | 100000 | $0.00 | 100000 | I | See Explanation of Responses (2) |
Class B Common Stock | (4) | 2/24/2022 | | C | | | 100000 | (4) | (4) | Class A Common Stock | 100000 | $0.00 | 0 | I | See Explanation of Responses (2) |
Explanation of Responses: |
(1) | Represents the conversion of Class B Common Stock into Class A Common Stock held of record by TF Investment Holdings LLC. |
(2) | Represents shares held directly by TF Investment Holdings LLC. Gary Trainor is the sole manager of TF Investment Holdings LLC and has sole voting and dispositive power with respect to the shares held by TF Investment Holdings LLC. |
(3) | The shares subject to the option are fully vested and exercisable. |
(4) | Class B Common Stock is convertible at any time, at the holder's election and automatically in connection with certain transfers and upon certain other events, into an equal number of shares of Class A Common Stock and has no expiration date. |
Remarks: Exhibit 24 - Power of Attorney |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Trainor Gary 18390 NE 68TH ST. REDMOND, WA 98052 | X |
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Signatures
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/s/ Andrew Gerber, Attorney-in-Fact | | 2/25/2022 |
**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 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 control number. |
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