# EDGAR Filing Document

**Accession Number:** 0001819881
**File Stem:** 0001213900-23-013686
**Filing Date:** 2023-2
**Character Count:** 15938
**Document Hash:** 2e5b9695100cce11b04b41f1848ff422
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001213900-23-013686.hdr.sgml**: 20230222

**ACCESSION NUMBER**: 0001213900-23-013686

**CONFORMED SUBMISSION TYPE**: 4

**PUBLIC DOCUMENT COUNT**: 1

**CONFORMED PERIOD OF REPORT**: 20230222

**FILED AS OF DATE**: 20230222

**DATE AS OF CHANGE**: 20230222

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** GTCR FUND XI/B LP
- **CENTRAL INDEX KEY:** 0001591435
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39627
- **FILM NUMBER:** 23653405

**BUSINESS ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
- **BUSINESS PHONE:** (312) 382-2200

**MAIL ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** GTCR FUND XI/C LP
- **CENTRAL INDEX KEY:** 0001591436
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39627
- **FILM NUMBER:** 23653404

**BUSINESS ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
- **BUSINESS PHONE:** (312) 382-2200

**MAIL ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** GTCR-Ultra Holdings, LLC
- **CENTRAL INDEX KEY:** 0001714612
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39627
- **FILM NUMBER:** 23653408

**BUSINESS ADDRESS:**
- **STREET 1:** C/O GTCR MANAGEMENT XI LLC
- **STREET 2:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
- **BUSINESS PHONE:** (312) 382-2200

**MAIL ADDRESS:**
- **STREET 1:** C/O GTCR MANAGEMENT XI LLC
- **STREET 2:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** GTCR PARTNERS XI/A&C LP
- **CENTRAL INDEX KEY:** 0001828028
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39627
- **FILM NUMBER:** 23653406

**BUSINESS ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
- **BUSINESS PHONE:** (312) 382-2200

**MAIL ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** GTCR PARTNERS XI/B LP
- **CENTRAL INDEX KEY:** 0001827959
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39627
- **FILM NUMBER:** 23653407

**BUSINESS ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
- **BUSINESS PHONE:** (312) 382-2200

**MAIL ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** GTCR INVESTMENT XI LLC
- **CENTRAL INDEX KEY:** 0001827977
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39627
- **FILM NUMBER:** 23653409

**BUSINESS ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
- **BUSINESS PHONE:** (312) 382-2200

**MAIL ADDRESS:**
- **STREET 1:** 300 NORTH LASALLE STREET, SUITE 5600
- **CITY:** CHICAGO
- **STATE:** IL
- **ZIP:** 60654
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Paya Holdings Inc.
- **CENTRAL INDEX KEY:** 0001819881
- **STANDARD INDUSTRIAL CLASSIFICATION:** SERVICES-BUSINESS SERVICES, NEC [7389]
- **IRS NUMBER:** 852199433
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 303 PERIMETER CENTER NORTH
- **STREET 2:** SUITE 600
- **CITY:** ATLANTA
- **STATE:** GA
- **ZIP:** 30346
- **BUSINESS PHONE:** (800) 261-0240

**MAIL ADDRESS:**
- **STREET 1:** 303 PERIMETER CENTER NORTH
- **STREET 2:** SUITE 600
- **CITY:** ATLANTA
- **STATE:** GA
- **ZIP:** 30346

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** FINTECH ACQUISITION CORP III PARENT CORP
- **DATE OF NAME CHANGE:** 20200731

### UNITED STATES SECURITIES AND EXCHANGE COMMISSION
**Washington, D.C. 20549**

## FORM 4

### STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

[x] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

[ ] Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan for the purchase or sale of equity securities of the issuer that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>GTCR INVESTMENT XI LLC<br><sub>(Last) (First) (Middle)</sub><br>300 NORTH LASALLE STREET<br>SUITE 5600<br><sub>(Street)</sub><br>CHICAGO, IL 60654<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-22 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Paya Holdings Inc. [ PAYA ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>GTCR-Ultra Holdings, LLC<br><sub>(Last) (First) (Middle)</sub><br>300 NORTH LASALLE STREET<br>SUITE 5600<br><sub>(Street)</sub><br>CHICAGO, IL 60654<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-22 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Paya Holdings Inc. [ PAYA ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>GTCR PARTNERS XI/B LP<br><sub>(Last) (First) (Middle)</sub><br>300 NORTH LASALLE STREET<br>SUITE 5600<br><sub>(Street)</sub><br>CHICAGO, IL 60654<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-22 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Paya Holdings Inc. [ PAYA ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>GTCR PARTNERS XI/A&C LP<br><sub>(Last) (First) (Middle)</sub><br>300 NORTH LASALLE STREET<br>SUITE 5600<br><sub>(Street)</sub><br>CHICAGO, IL 60654<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-22 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Paya Holdings Inc. [ PAYA ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>GTCR FUND XI/B LP<br><sub>(Last) (First) (Middle)</sub><br>300 NORTH LASALLE STREET<br>SUITE 5600<br><sub>(Street)</sub><br>CHICAGO, IL 60654<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-22 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Paya Holdings Inc. [ PAYA ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>GTCR FUND XI/C LP<br><sub>(Last) (First) (Middle)</sub><br>300 NORTH LASALLE STREET<br>SUITE 5600<br><sub>(Street)</sub><br>CHICAGO, IL 60654<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-22 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Paya Holdings Inc. [ PAYA ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

## Table I - Non-Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | 3. Transaction Code (V) | 3. Transaction Code (V) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | Code | V | Amount | (A) or (D) | Price | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| Common Stock | 2023-02-22 |  | U |  | 45234022<sup>(1)</sup> | D | 9.75<sup>(1)</sup> | 0 | I | See footnote<sup>(2)(3)</sup> |

---

## Table II - Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | 4. Transaction Code (V) | 4. Transaction Code (V) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 6. Date Exercisable and Expiration Date | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Underlying Securities | 7. Title and Amount of Underlying Securities | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |

---

### Footnotes:

(1) Pursuant to that certain Agreement and Plan of Merger (the "Merger Agreement") by and among Paya Holdings Inc., Nuvei Corporation ("Parent"), and Pinnacle Merger Sub, Inc., a wholly owned subsidiary of Parent dated as of January 8, 2023, these shares of common stock, par value $0.0001 per share were tendered prior to the Offer Expiration Time (as defined in the Merger Agreement) and disposed of at the Effective Time (as defined in the Merger Agreement) in exchange for the right to receive a cash payment of $9.75 per share, without interest, subject to any applicable withholding of taxes.

(2) Reflects securities directly held by GTCR-Ultra Holdings, LLC ("Holdings"). GTCR Fund XI/B LP ("Fund XI/B") and GTCR Fund XI/C LP ("Fund XI/C") each hold an economic interest in Holdings and possess the right to appoint certain managers to Holdings' board of managers. Each of Fund XI/B and Fund XI/C is controlled by its general partner, GTCR Partners XI/B LP ("Partners XI/B") and GTCR Partners XI/A&C LP ("Partners XI/A&C"), respectively. Partners XI/B and Partners XI/A&C are controlled by their general partner, GTCR Investment XI LLC ("Investment XI"). As such, each of Fund XI/B, Fund XI/C, Partners XI/B, Partners XI/A&C and Investment XI may be deemed to possess indirect beneficial ownership of the Common Stock held by Holdings. Decisions of Investment XI are made by a vote of a majority of its managers, and, as a result, no single person has voting or dispositive authority over such securities. (Continued in Footnote 3).

(3) Each of the foregoing entities (other than Holdings) and the individual members of the GTCR Board of Managers disclaims beneficial ownership of the shares reported hereby, except to the extent of their pecuniary interest therein, and this report shall not be deemed an admission that the reporting person is the beneficial owner of the securities for purposes of Section 16 or for any other purpose.

**Remarks:**
Investment XI, acting through Fund XI/B and Fund XI/C, previously had the right to designate up to five nominees for election to the board of directors of the Issuer.

**Signature:** GTCR INVESTMENT XI LLC, By: /s/ Jeffrey S. Wright, by power of attorney  
**Date:** 2023-02-22

**Signature:** GTCR- ULTRA HOLDINGS, LLC, By: /s/ Jeffrey S. Wright, by power of attorney  
**Date:** 2023-02-22

**Signature:** GTCR PARTNERS XI/B LP, By: /s/ Jeffrey S. Wright, by power of attorney  
**Date:** 2023-02-22

**Signature:** GTCR PARTNERS XI/A&C LP, By: /s/ Jeffrey S. Wright, by power of attorney  
**Date:** 2023-02-22

**Signature:** GTCR FUND XI/B LP, By: /s/ Jeffrey S. Wright, by power of attorney  
**Date:** 2023-02-22

**Signature:** GTCR FUND XI/C LP, By: /s/ Jeffrey S. Wright, by power of attorney  
**Date:** 2023-02-22

### Remarks:

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.**