| 表格4 |
美國證券交易委員會 華盛頓特區 20549 受益人所有權變更聲明 根據1934年證券交易法第16(a)條或1940年投資公司法第30(h)條申報 或1940年投資公司法第30(h)節 |
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| 如果不再受到第16條的約束，請勾選此框。 表格4或表格5的義務可能會繼續。 查看 指示1(b)。 | |||||||||||||||||
| 勾選此框表示根據合同、指令或書面計劃進行了一項交易，該交易涉及發行人的股票證券購買或銷售，旨在滿足規則10b5-1(c)的肯定防禦條件。 請參見說明10。 | |||||||||||||||||
1. 報告人的姓名和地址*
(街道)
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2. 發行者名稱 和 逐筆明細或交易標的
Paymentus控股公司 [ PAY ] |
5. 報告人和發行人之間的關係
(檢查所有適用項)
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3. 最早交易日期
（月/日/年） 12/05/2024 | ||||||||||||||||||||||||||
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4. 如果是修正，原始提交日期
（月/日/年） |
6. 個人或聯合/團體申報（請勾選適用的選項）
|
| 表 I - 非衍生證券的獲取、處置或實益擁有 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1. 證券名稱（說明書第3條） | 2. 交易日期 （月/日/年） | 2A. 認爲的執行日期（如有） （月/日/年） | 3. 交易代碼（指令 8） | 4. 獲取的證券 (A) 或處置的證券 (D) (指令 3、4和5) | 5. 報告交易後實益擁有的證券數量 (指令 3和4) | 6. 所有權形式：直接（D）或間接（I）（指令 4） | 7. 間接享有所有權的性質（說明 4） | |||
| 代碼 | V | 金額 | (A) 或 (D) | 價格 | ||||||
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表II - 獲取、處置或實益擁有的衍生證券 (例如，賣權，買權，Warrants，期權，可轉換證券) | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. 衍生證券的名稱（Instr. 3） | 2. 衍生證券的轉換或行權價格 | 3. 交易日期 （月/日/年） | 3A. 假定執行日期（如有） （月/日/年） | 4. 交易代碼（說明書第8部分） | 5. 獲取（A）或處置（D）的衍生證券數量（指示符 3、4和5） | 6. 行使日期和到期日 (月/日/年) | 7. 衍生證券所基於的證券名稱和數量（Instr. 3和4） | 8. 衍生證券價格（Instr. 5） | 9. 報告交易後有益擁有的衍生證券數量 (指令 4) | 10. 所有權形式：直接（D）或間接（I） (指令 4) | 11. 間接有益所有權的性質 (指令 4) | ||||
| 代碼 | V | (A) | (D) | 行使日期 | 到期日 | 標題 | 金額或股票數量 | ||||||||
| B類普通股 | (1) | 12/05/2024 | J(2) | 7,422,692 | (1) | (1) | A級普通股 | 7,422,692 | $0(2) | 56,518,054 | I | Accel-KKR資本合作伙伴CV III，有限合夥(3)(4)(5) | |||
| B類普通股 | (1) | 12/05/2024 | J(2) | 577,308 | (1) | (1) | A級普通股 | 577,308 | $0(2) | 4,441,502 | I | Accel-KKR成員基金，有限責任公司(3)(4)(5) | |||
| B類普通股 | (1) | (1) | (1) | A級普通股 | 3,025,270 | 3,025,270 | I | Accel-KKR增長資本合夥人第三期，有限合夥(3)(4)(5) | |||||||
| B類普通股 | (1) | (1) | (1) | A級普通股 | 101,395 | 101,395 | I | Accel-KKR增長資本合夥人第二期戰略基金，有限合夥(3)(4)(5) | |||||||
| B類普通股 | (1) | (1) | (1) | A級普通股 | 1,195,150 | 1,195,150 | I | Accel-KKR增長資本合夥人II，LP(3)(4)(5) | |||||||
| B類普通股 | (1) | (1) | (1) | A級普通股 | 813,057(6) | 813,057 | I | AKKR戰略資本LP(3)(4)(5) | |||||||
| B類普通股 | (1) | (1) | (1) | A級普通股 | 182,033(7) | 182,033 | I | AKKR SC GPI控股公司LP(3)(4)(5) | |||||||
1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
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1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
| ||||||||||||||||||||||||
1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
| ||||||||||||||||||||||||
1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
| ||||||||||||||||||||||||
1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
| ||||||||||||||||||||||||
1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
| ||||||||||||||||||||||||
1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
| ||||||||||||||||||||||||
1. 報告人的姓名和地址*
(街道)
報告人（們）與發行人的關係
|
| Explanation of Responses: |
| 1. 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. |
| 2. In-kind pro rata distribution from the Reporting Person to its partners, without consideration. |
| 3. Accel-KKR Holdings GP, LLC , or Topco GP (for which decision making is controlled by Mr. Palumbo and Mr. Barnds), has voting and investment power over the shares of Common Stock of the Issuer owned by (i) Accel-KKR Capital Partners CV III, LP, or CV III; (ii) Accel-KKR Growth Capital Partners III, LP, or GC III; (iii) Accel-KKR Growth Capital Partners II Strategic Fund, LP, or GC II Strategic; (iv) Accel-KKR Growth Capital Partners II, LP, or GC II; (v) (v) Accel-KKR Members Fund, LLC, or Members Fund; (vi) AKKR Strategic Capital LP, or SC; and (vii) AKKR SC GPI HoldCo LP, or SC GPI. |
| 4. (Continued from footnote 3) AKKR Fund III Management Company CV, LP, or CV III GP, is the sole general partner of CV III. AKKR Growth Capital Management Company III, LP, or GC III GP, is the sole general partner of GC III. AKKR Growth Capital Management Company II, LP, or GC II GP, is the sole general partner of GC II Strategic and GC II. AKKR Strategic Capital GP, or SC GP, is the sole general partner of SC. AKKR Management Company, LLC, or UGP, is the sole managing member of Members Fund and the sole general partner of CV III GP, GC III GP, GC II GP, SC GP and SC GPI. Topco GP, is the sole managing member of UGP. AKKR Fund II Management Company, LP, |
| 5. (Continued from footnote 4) or the Management Company, is the sole management company of each of the Accel-KKR Funds, and UGP is the general partner of the Management Company. Each of the Reporting Persons disclaims beneficial ownership of the reported securities except to the extent of such Reporting Person's pecuniary interest therein. Mr. Palumbo and Mr. Barnds have separately filed Form 4s reporting their interests. |
| 6. Includes 542,000 shares received from CV III in the distribution described in footnote 2. Such shares were previously reported as indirectly owned through CVIII. |
| 7. Includes 121,515 shares received from CV III in the distribution described in footnote 2. Such shares were previously reported as indirectly owned through CVIII. |
| Accel-KKR Holdings GP, LLC, /s/ Thomas C. Barnds, as its authorized signatory | 12/06/2024 | |
| Accel-KKR Capital Partners CV III, LP, /s/ Thomas C. Barnds, as its authorized signatory | 12/06/2024 | |
| Accel-KKR Growth Capital Partners III, LP, /s/ Thomas C. Barnds, as its authorized signatory | 12/06/2024 | |
| Accel-KKR Growth Capital Partners II Strategic Fund, LP, /s/ Thomas C. Barnds, as its authorized signatory | 12/06/2024 | |
| Accel-KKR Growth Capital Partners II, LP, /s/ Thomas C. Barnds, as its authorized signatory | 12/06/2024 | |
| AKKR Strategic Capital LP /s/ Thomas C. Barnds, as its authorized signatory | 12/06/2024 | |
| AKKR SC GPI HoldCo LP /s/ Thomas C. Barnds, as its authorized signatory | 12/06/2024 | |
| ** 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. | ||