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
|
OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person*
3 WEST PACES FERRY ROAD |
SUITE 200 |
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year) 11/06/2023
|
3. Issuer Name and Ticker or Trading Symbol
Repay Holdings Corp
[ RPAY ]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
X |
Officer (give title below) |
|
Other (specify below) |
Executive Vice President |
|
5. If Amendment, Date of Original Filed
(Month/Day/Year)
|
6. Individual or Joint/Group Filing (Check Applicable Line)
X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
|
Table I - Non-Derivative Securities Beneficially Owned |
1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
|
3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
4. Nature of Indirect Beneficial Ownership (Instr.
5)
|
Class A Common Stock |
121,888
|
D |
|
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 Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
|
4. Conversion or Exercise Price of Derivative Security
|
5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
|
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of Responses: |
Remarks: |
|
/s/Tyler B. Dempsey, as Attorney-in-Fact |
11/13/2023 |
|
** 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
Know all by these presents that the undersigned, does hereby make, constitute
and appoint each of Tyler B. Dempsey and Timothy J. Murphy, or any one of them,
as a true and lawful attorney-in-fact of the undersigned with full powers of
substitution and revocation, for and in the name, place and stead of the
undersigned (in the undersigned's individual capacity), to execute and deliver
such forms that the undersigned may be required to file with the U.S. Securities
and Exchange Commission as a result of the undersigned's ownership of or
transactions in securities of Repay Holdings Corporation (the "Company") (i)
pursuant to Section 16(a) of the Securities Exchange Act of 1934, as amended,
including without limitation, statements on Form 3, Form 4 and Form 5 (including
any amendments thereto) and (ii) in connection with any applications for EDGAR
access codes, including without limitation the Form ID. The Power of Attorney
shall remain in full force and effect until the undersigned is no longer
required to file Forms 3, 4 and 5 with regard to his or her ownership of or
transactions in securities of the Company, unless earlier revoked in writing.
The undersigned acknowledges that Tyler B. Dempsey and Timothy J. Murphy are not
assuming any of the undersigned's responsibilities to comply with Section 16 of
the Securities Exchange Act of 1934, as amended.
By: /s/ Alex Cohen
Name: Alexander M. Cohen
Date: November 8, 2023