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
OMB APPROVAL
OMB Number: 3235-0104
Estimated average burden
hours per response: 0.5
1. Name and Address of Reporting Person*
Hartje Karen

(Last) (First) (Middle)
251 1ST AVENUE N
SUITE 200

(Street)
MINNEAPOLIS MN 55401

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/11/2021
3. Issuer Name and Ticker or Trading Symbol
Sezzle Inc. [ SZL.AX ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Financial Officer
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)
Common Stock, $.00001 par value 39,245(1) 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
Stock Options (right to buy) (2) 08/25/2028 Common Stock 1,735,000 $0.05 D
Stock Options (right to buy) (3) 07/26/2029 Common Stock 500,000 $0.84 D
Stock Options (right to buy) (4) 05/22/2030 Common Stock 390,625 $1.37 D
Explanation of Responses:
1. Includes 39,245 Restricted Stock Units ("RSU"). Each RSU represents the right to receive one share of Common Stock.
2. 1,337,395 shares are currently vested, the remainder vests in equal installments monthly, being fully vested on 8/26/2022.
3. 229,167 shares are currently vested, the remainder vests in equal installments monthly, being fully vested on 7/27/2023.
4. Represents the portion of a stock option for which performance conditions have been satisfied, to vest on January 1, 2023. The remaining 781,250 shares will vest on January 1, 2023 to the extent the applicable performance conditions have been satisfied.
Remarks:
Exhibit 24.1 Power of Attorney attached hereto.
/s/ Don McConnell, as Attorney-in-Fact 06/11/2021
** 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).
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.