|
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL 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 |
|
| ||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
| 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 control number. | |||
| 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 of Derivative Security: 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 | ||||
| Series A Preferred Stock | (4) | (4) | Common Stock | 2,614,561 | $ (4) | I | By Providence Public Master L.P. (3) (4) (5) |
| Series A Preferred Stock | (6) | (6) | Common Stock | 1,743,041 | $ (6) | I | By Providence Butternut Co-Investment L.P. (3) (6) (7) |
| Reporting Owner Name / Address | Relationships | |||
| Director | 10% Owner | Officer | Other | |
| Noell Robert Davis C/O DOUBLEVERIFY HOLDINGS, INC. 233 SPRING STREET NEW YORK, NY 10013 |
X | X | ||
| /s/ Andrew E. Grimmig, as Attorney-in-Fact for Robert David Noell | 04/20/2021 | |
| **Signature of Reporting Person | Date |
| * | 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). |
| (1) | The securities reported are held directly by Providence VII U.S. Holdings L.P. ("Providence VII") and may be deemed to be beneficially owned by Providence Equity GP VII-A L.P. ("Providence GP") because Providence GP is the general partner of Providence VII. Jonathan M. Nelson, R. Davis Noell, J. David Phillips, Karim A. Tabet, Andrew A. Tisdale and Michael J. Dominguez control Providence Holdco (International) GP Ltd. ("Holdco"), which is the general partner of Providence Fund Holdco (International) L.P. Providence Fund Holdco (International) L.P. is the general partner of PEP VII-A International Ltd., which is the general partner of Providence GP. |
| (2) | Jonathan M. Nelson, R. Davis Noell, J. David Phillips, Karim A. Tabet, Andrew A. Tisdale and Michael J. Dominguez may be deemed to exercise voting and investment power over, and thus may be deemed to beneficially own, the securities held by Providence VII due to their relationships with Holdco. R. Davis Noell hereby disclaims beneficial ownership of the shares held by Providence VII, except to the extent of his pecuniary interest therein, and this form shall not be construed as an admission that R. Davis Noell is the beneficial owner of any of the securities reported on this form. |
| (3) | The record and other beneficial owners of the reported securities have separately filed Form 3s. |
| (4) | The securities reported are held directly by Providence Public Master L.P., which has the right to acquire 871,520 shares of common stock of DoubleVerify Holdings, Inc. (the "Issuer") upon the conversion of 2,614,561 shares of Series A Preferred Stock at a conversion rate of one-third of a share of common stock for every three shares of Series A Preferred Stock. Such conversion may be effected at any time while such preferred shares are outstanding. Each outstanding share of Series A Preferred Stock will automatically convert into one-third of a share of common stock of the Issuer for no additional consideration upon the completion of the Issuer's initial public offering. Providence Public Master L.P. is an investment fund affiliated with Providence VII and thus Providence VII and R. Davis Noell may be deemed to beneficially own the securities held by Providence Public Master L.P. |
| (5) | R. Davis Noell hereby disclaims beneficial ownership of the securities held by Providence Public Master L.P., except to the extent of his pecuniary interest therein, and this form shall not be construed as an admission that R. Davis Noell is the beneficial owner of any of the securities reported on this form. |
| (6) | The securities reported are held directly by Providence Butternut Co-Investment L.P., which has the right to acquire 581,014 shares of common stock of the Issuer upon the conversion of 1,743,041 shares of Series A Preferred Stock at a conversion rate of one-third of a share of common stock for every three shares of Series A Preferred Stock. Such conversion may be effected at any time while such preferred shares are outstanding. Each outstanding share of Series A Preferred Stock will automatically convert into one-third of a share of common stock of the Issuer for no additional consideration upon the completion of the Issuer's initial public offering. Providence Butternut Co-Investment L.P. is an investment fund affiliated with Providence VII and thus Providence VII and R. Davis Noell may be deemed to beneficially own the securities held by Providence Butternut Co-Investment L.P. |
| (7) | R. Davis Noell hereby disclaims beneficial ownership of the securities held by Providence Butternut Co-Investment L.P., except to the extent of his pecuniary interest therein, and this form shall not be construed as an admission that R. Davis Noell is the beneficial owner of any of the securities reported on this form. |
| Remarks: Exhibit List: Ex.24 - Power of Attorney | |