| 表格4 |
美国证券交易委员会 华盛顿特区 20549 受益人所有权变更声明 根据1934年证券交易法第16(a)条或1940年投资公司法第30(h)条申报 或1940年投资公司法第30(h)节 |
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| 如果不再受到第16条的约束，请勾选此框。 表格4或表格5的义务可能会继续。 查看 指示1(b)。 | |||||||||||||||||
| 勾选此框表示根据合同、指令或书面计划进行了一项交易，该交易涉及发行人的股票证券购买或销售，旨在满足规则10b5-1(c)的肯定防御条件。 请参见说明10。 | |||||||||||||||||
1. 报告人的姓名和地址*
(街道)
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2. 发行者名称 和 逐笔明细或交易标的
Paymentus控股公司 [ PAY ] |
5. 报告人和发行人之间的关系
(检查所有适用项)
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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. 个人或联合/团体申报（请勾选适用的选项）
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| 表 I - 非衍生证券的获取、处置或实益拥有 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1. 证券名称（说明书第3条） | 2. 交易日期 （月/日/年） | 2A. 认为的执行日期（如有） （月/日/年） | 3. 交易代码（指令 8） | 4. 获取的证券 (A) 或处置的证券 (D) (指令 3、4和5) | 5. 报告交易后实益拥有的证券数量 (指令 3和4) | 6. 所有权形式：直接（D）或间接（I）（指令 4） | 7. 间接享有所有权的性质（说明 4） | |||
| 代码 | V | 金额 | (A) 或 (D) | 价格 | ||||||
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表II - 获取、处置或实益拥有的衍生证券 (例如，卖权，买权，Warrants，期权，可转换证券) | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. 衍生证券的名称（Instr. 3） | 2. 衍生证券的转换或行权价格 | 3. 交易日期 （月/日/年） | 3A. 假定执行日期（如有） （月/日/年） | 4. 交易代码（说明书第8部分） | 5. 获取（A）或处置（D）的衍生证券数量（指示符 3、4和5） | 6. 行使日期和到期日 (月/日/年) | 7. 衍生证券所基于的证券名称和数量（Instr. 3和4） | 8. 衍生证券价格（Instr. 5） | 9. 报告交易后有益拥有的衍生证券数量 (指令 4) | 10. 所有权形式：直接（D）或间接（I） (指令 4) | 11. 间接有益所有权的性质 (指令 4) | ||||
| 代码 | V | (A) | (D) | 行使日期 | 到期日 | 标题 | 金额或股票数量 | ||||||||
| B类普通股 | (1) | 12/05/2024 | J(2) | 7,422,692 | (1) | (1) | A级普通股 | 7,422,692 | $0(2) | 56,518,054 | I | Accel-KKR资本合作伙伴CV III，有限合伙(3)(4)(5) | |||
| B类普通股 | (1) | 12/05/2024 | J(2) | 577,308 | (1) | (1) | A级普通股 | 577,308 | $0(2) | 4,441,502 | I | Accel-KKR成员基金，有限责任公司(3)(4)(5) | |||
| B类普通股 | (1) | (1) | (1) | A级普通股 | 3,025,270 | 3,025,270 | I | Accel-KKR增长资本合伙人第三期，有限合伙(3)(4)(5) | |||||||
| B类普通股 | (1) | (1) | (1) | A级普通股 | 101,395 | 101,395 | I | Accel-KKR增长资本合伙人第二期战略基金，有限合伙(3)(4)(5) | |||||||
| B类普通股 | (1) | (1) | (1) | A级普通股 | 1,195,150 | 1,195,150 | I | Accel-KKR增长资本合伙人II，LP(3)(4)(5) | |||||||
| B类普通股 | (1) | (1) | (1) | A级普通股 | 813,057(6) | 813,057 | I | AKKR战略资本LP(3)(4)(5) | |||||||
| B类普通股 | (1) | (1) | (1) | A级普通股 | 182,033(7) | 182,033 | I | AKKR SC GPI控股公司LP(3)(4)(5) | |||||||
1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
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1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
| ||||||||||||||||||||||||
1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
| ||||||||||||||||||||||||
1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
| ||||||||||||||||||||||||
1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
| ||||||||||||||||||||||||
1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
| ||||||||||||||||||||||||
1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
| ||||||||||||||||||||||||
1. 报告人的姓名和地址*
(街道)
报告人（们）与发行人的关系
|
| 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. | ||