FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Affirm Holdings, Inc. [ AFRM ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 01/15/2021 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction 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 | ||||||
Class A Common Stock | 01/15/2021 | P | 75,000 | A | $49 | 75,000 | I | By Fund(1) | ||
Class A Common Stock | 01/15/2021 | C | 550,000 | A | (2) | 1,486,909 | I | By Fund(3) | ||
Class A Common Stock | 3,994,807 | I | By Fund(4) | |||||||
Class A Common Stock | 1,074,604 | I | By Fund(5) | |||||||
Class A Common Stock | 56,539 | I | By Fund(6) | |||||||
Class A Common Stock | 2,205,293 | I | By Fund(7) | |||||||
Class A Common Stock | 545,294 | I | By Fund(8) | |||||||
Class A Common Stock | 27,418 | I | By Fund(9) | |||||||
Class A Common Stock | 60,429 | I | By Fund(10) | |||||||
Class A Common Stock | 142,857 | I | By LLC(11) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction 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 (Month/Day/Year) | 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: 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 | (2) | 01/15/2021 | C | 550,000 | (2) | (2) | Class A Common Stock | 550,000 | $0.00 | 386,909 | I | By Fund(3) | |||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 3,994,807 | 3,994,807 | I | By Fund(4) | |||||||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 1,074,604 | 1,074,604 | I | By Fund(5) | |||||||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 56,539 | 56,539 | I | By Fund(6) | |||||||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 2,205,293 | 2,205,293 | I | By Fund(7) | |||||||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 545,294 | 545,294 | I | By Fund(8) | |||||||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 27,418 | 27,418 | I | By Fund(9) | |||||||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 60,429 | 60,429 | I | By Fund(10) | |||||||
Class B Common Stock | (2) | (2) | (2) | Class A Common Stock | 142,857 | 142,857 | I | By LLC(11) |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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Explanation of Responses: |
1. Shares held by FF Affirm Growth, LLC ("FF-Affirm"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-Affirm and, accordingly, may be deemed to beneficially own the shares held by FF-Affirm. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer, files separate Section 16 reports, and reported this purchase on a Form 4 filed on January 15, 2021. |
2. Each share of the Issuer's Class B common stock, par value $0.00001 per share ("Class B Common Stock"), is convertible at any time into one share of the Issuer's Class A common stock, par value $0.00001 per share ("Class A Common Stock"). The Class B Common Stock has no expiration date. |
3. Shares held by The Founders Fund Growth, LP ("FF-G"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-G and, accordingly, may be deemed to beneficially own the shares held by FF-G. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports. |
4. Shares held by The Founders Fund V, LP ("FF-V"). The Founders Fund V Management, LLC ("FF-VM") is the general partner of FF-V and may be deemed to beneficially own the shares held by FF-V. Peter Thiel and Brian Singerman have shared voting and investment power over the shares held by FF-V and, accordingly, may be deemed to beneficially own the shares held by FF-V. Each of FF-VM, Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his or its respective pecuniary interest therein. |
5. Shares held by The Founders Fund V Principals Fund, LP ("FF-VP"). FF-VM is the general partner of FF-VP and may be deemed to beneficially own the shares held by FF-VP. Peter Thiel and Brian Singerman have shared voting and investment power over the shares held by FF-VP and, accordingly, may be deemed to beneficially own the shares held by FF-VP. Each of FF-VM, Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his or its respective pecuniary interest therein. |
6. Shares held by The Founders Fund V Entrepreneurs Fund, LP ("FF-VE"). FF-VM is the general partner of FF-VE and may be deemed to beneficially own the shares held by FF-VE. Peter Thiel and Brian Singerman have shared voting and investment power over the shares held by FF-VE and, accordingly, may be deemed to beneficially own the shares held by FF-VE. Each of FF-VM, Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his or its respective pecuniary interest therein. |
7. Shares held by The Founders Fund VI, LP ("FF-VI"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-VI and, accordingly, may be deemed to beneficially own the shares held by FF-VI. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports. |
8. Shares held by The Founders Fund VI Principals Fund, LP ("FF-VIP"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-VIP and, accordingly, may be deemed to beneficially own the shares held by FF-VIP. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports. |
9. Shares held by The Founders Fund VI Entrepreneurs Fund, LP ("FF-VIE"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-VIE and, accordingly, may be deemed to beneficially own the shares held by FF-VIE. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports. |
10. Shares held by The Founders Fund Growth Principals Fund, LP ("FF-GP"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-GP and, accordingly, may be deemed to beneficially own the shares held by FF-GP. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports. |
11. Shares held by Rivendell Investments 3 LLC. Peter Thiel is the beneficial owner of Rivendell Investments 3 LLC and has sole voting and investment power over the shares held by Rivendell Investments 3 LLC. |
Remarks: |
The Founders Fund Management V LLC, By /s/ Brian Singerman, Managing Member | 01/20/2021 | |
The Founders Fund V Entrepreneurs Fund, LP, By The Founders Fund Management V LLC, General Partner, By /s/ Brian Singerman, Managing Member | 01/20/2021 | |
The Founders Fund V Principals Fund, LP, By The Founders Fund Management V LLC, General Partner, By /s/ Brian Singerman, Managing Member | 01/20/2021 | |
The Founders Fund V, LP, By The Founders Fund Management V LLC, General Partner, By /s/ Brian Singerman, Managing Member | 01/20/2021 | |
/s/ Peter Thiel | 01/20/2021 | |
/s/ Brian A. Singerman | 01/20/2021 | |
** 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 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. |