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
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1. Name and Address of Reporting Person*
Salaymeh Omar

(Last) (First) (Middle)
C/O GTY TECHNOLOGY HOLDINGS INC.
1180 NORTH TOWN CENTER DRIVE, SUITE 100

(Street)
LAS VEGAS NV 89144

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
04/19/2021
3. Issuer Name and Ticker or Trading Symbol
GTY Technology Holdings Inc. [ GTYH ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
CEO of Bonfire
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 97,025 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 (1) (1) Common Stock 51,372 $2.4458 D
Restricted Stock Units (2) (2) Common Stock 50,639 (2) D
Explanation of Responses:
1. The reporting person has been granted 51,372 stock options (the "Options"). Previously, 44,512 of the Options vested. Subject to the reporting person continuing to be employed with the issuer, an additional 1,712 of the Options vest each month. Each vested Option is exercisable at a price of $2.4458 for one share of the issuer's common stock.
2. Each restricted stock unit represents a contingent right to receive one share of the issuer's common stock. If the reporting person remains employed with the issuer at such time, 26,562 restricted stock units will vest on February 19, 2022; 17,410 restricted stock units will vest on February 19, 2023; and 6,667 restricted stock units will vest on February 19, 2024. Restricted stock units may be settled in shares of the issuer's common stock or cash.
Remarks:
See Exhibit 24.1 - Power of Attorney.
/s/ Jon C. Bourne, Attorney-in-Fact 04/23/2021
** 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.
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