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
 
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1. Name and Address of Reporting Person*
Moore Jacob Hamilton

(Last) (First) (Middle)
3 WEST PACES FERRY ROAD
SUITE 200

(Street)
ATLANTA GA 30305

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
03/11/2020
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 V Common Stock(1) 1 D
Class A Common Stock 213,325(2) 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
Post-Merger Repay Units(3) 01/11/2020 (3) Class A Common Stock 106,013 (3) D
Explanation of Responses:
1. These shares of Class V common stock ("Class V Common Stock") of the Issuer provide no economic rights in the Issuer to the holder thereof. However, each holder of Class V Common Stock will be entitled to vote with the holders of Class A common stock (the "Class A Common Stock") of the Issuer, with each share of Class V Common Stock entitling the holder to a number of votes equal to the number of Post-Merger Repay Units (as described below) held by such holder of Class V Common Stock at the time of such vote.
2. Includes 128,218 shares of restricted Class A Common Stock that vests as follows: (a) 25% shall vest on August 14, 2020 and (b) 2.08 1/3% shall vest on each monthly anniversary date of the first vesting date.
3. These "Post-Merger Repay Units" represent non-voting limited liability company interests in Hawk Parent Holdings, LLC. Pursuant to the terms of an exchange agreement, these Post-Merger Repay Units may be exchanged at the discretion of the holder for shares of Class A Common Stock on a one-for-one basis, or, at the option of the Issuer, for cash. These exchange rights do not expire.
Remarks:
Exhibit List: Exhibit 24 - Power of Attorney
/s/Tyler B. Dempsey, as Attorney-in-Fact 03/12/2020
** 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).
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Exhibit 24

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/ Jacob Hamilton Moore
Name: Jacob Hamilton Moore


Date: March 12, 2020