Statement of Changes in Beneficial Ownership (4)
October 15 2021 - 04:18PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
|
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APPROVAL
OMB Number: 3235-0287
Estimated average burden
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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 * COHEN BETSY
Z |
2. Issuer Name and Ticker or Trading
Symbol Fintech Acquisition Corp V [ FTCV ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)__X__
Director _____
10% Owner
_____ Officer (give title
below) _____ Other
(specify below)
|
(Last)
(First)
(Middle)
2929 ARCH STREET, SUITE 1703 |
3. Date of Earliest Transaction (MM/DD/YYYY)
4/4/2021
|
(Street)
PHILADELPHIA, PA 19104
(City)
(State)
(Zip)
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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 |
Table I - Non-Derivative Securities Acquired, Disposed of, or
Beneficially Owned
|
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) |
Code |
V |
Amount |
(A) or (D) |
Price |
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible
securities)
|
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 |
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 Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct
(D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr.
4) |
Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Class B Common Stock |
(1) |
4/4/2021 |
|
J (2) |
|
|
33334 |
(1) |
(1) |
Class A Common Stock |
33334 |
$0.0029 |
1363222 (3) |
I |
By Cohen Sponsor Interests V,
LLC (4) |
Class B Common Stock |
(1) |
10/13/2021 |
|
J (2) |
|
|
2917 |
(1) |
(1) |
Class A Common Stock |
2917 |
$0.0029 |
1360305 (3) |
I |
By Cohen Sponsor Interests V,
LLC (4) |
Explanation of
Responses: |
(1) |
The shares of Class B common
stock will automatically convert into shares of Class A common
stock at the time of the issuer's initial business combination on a
one-for-one basis, subject to certain adjustments described in the
issuer's charter documents and have no expiration date. |
(2) |
Represents transfer of
membership interests to a new member of the issuer's sponsors at
the original purchase price. |
(3) |
The reporting person
disclaims beneficial ownership of these securities, except to the
extent of her pecuniary interest therein, and this report shall not
be deemed an admission that the reporting person is the beneficial
owner of such securities for any other purpose. |
(4) |
These shares are held
directly by the issuer's sponsors, FinTech Investor Holdings V, LLC
and FinTech Masala Advisors V, LLC, each of which is managed by
Cohen Sponsor Interests V, LLC. The reporting person is an indirect
owner of Cohen Sponsor Interests V, LLC. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
COHEN BETSY Z
2929 ARCH STREET, SUITE 1703
PHILADELPHIA, PA 19104 |
X |
|
|
|
Signatures
|
/s/ Amanda Abrams, as
attorney-in-fact |
|
10/15/2021 |
**Signature of
Reporting Person |
Date |
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