Annual Statement of Changes in Beneficial Ownership (5)
14 Februar 2022 - 10:10PM
Edgar (US Regulatory)
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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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Form 3 Holdings Reported
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Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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
*
Isaacman Jared | 2. Issuer Name and Ticker or Trading SymbolShift4 Payments, Inc. [FOUR] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director __X__ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Chairman & CEO |
(Last)
(First)
(Middle)
2202 N. IRVING ST | 3. Statement for Issuer's Fiscal Year Ended (MM/DD/YYYY) 12/31/2021 |
(Street)
ALLENTOWN, PA 18109
(City)
(State)
(Zip)
| 4. If Amendment, Date Original Filed(MM/DD/YYYY) | 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) | 2. Trans. Date | 2A. Deemed Execution Date, if any | 3. Trans. Code (Instr. 8) | 4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) |
Amount | (A) or (D) | Price |
Class C Common Stock | 12/1/2021 | | G | 96117 | D | $0.00 | 4529229 | I | See footnote (1) |
Class C Common Stock | 12/23/2021 | | G | 171822 | D | $0.00 | 0 (2) | D | |
Class A Common Stock | 12/23/2021 | | G | 42958 | D | $0.00 | 3442 | D | |
Class C Common Stock | 12/23/2021 | | G | 85911 | A | $0.00 | 85911 | I | By Daughter (3) |
Class C Common Stock | 12/23/2021 | | G | 85911 | A | $0.00 | 85911 | I | By Daughter (4) |
Table II - Derivative Securities Acquired, Disposed of, or 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 (MM/DD/YYYY) | 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 at End of Issuer's Fiscal Year (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | Securities held of record by Rook Holdings, Inc. ("Rook"). Mr. Isaacman is the sole stockholder of Rook and therefore may be deemed to have beneficial ownership with respect to such securities. |
(2) | On December 23, 2021, Rook transferred 171,322 shares of Class C Common Stock to the reporting person. |
(3) | Held by Jared Isaacman C/F Liv A. Isaacman UTMA. The reporting person disclaims beneficial ownership of these shares. |
(4) | Held by Jared Isaacman C/F Mila T. Isaacman UTMA. The reporting person disclaims beneficial ownership of these shares. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Isaacman Jared 2202 N. IRVING ST ALLENTOWN, PA 18109 | X | X | Chairman & CEO |
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Signatures
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/s/ Jordan Frankel, Attorney-in-Fact for Jared Isaacman | | 2/14/2022 |
**Signature of Reporting Person | Date |
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