Statement of Changes in Beneficial Ownership (4)
November 03 2021 - 6:06PM
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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3235-0287
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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
*
Rabois Keith |
2. Issuer Name and Ticker or Trading Symbol
Affirm Holdings, Inc.
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AFRM
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
ONE LETTERMAN DRIVE, BUILDING D, 5TH FLOOR |
3. Date of Earliest Transaction
(MM/DD/YYYY)
11/1/2021 |
(Street)
SAN FRANCISCO, CA 94129
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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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)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Class A Common Stock | 11/1/2021 | | S | | 2200 (1) | D | $151.5918 (2) | 77881 (3) | D | |
Class A Common Stock | 11/1/2021 | | S | | 5644 (1) | D | $152.3826 (4) | 72237 | D | |
Class A Common Stock | 11/1/2021 | | S | | 1829 (1) | D | $153.5346 (5) | 70408 | D | |
Class A Common Stock | 11/1/2021 | | S | | 5163 (1) | D | $154.5493 (6) | 65245 | D | |
Class A Common Stock | 11/1/2021 | | S | | 2168 (1) | D | $155.1485 (7) | 63077 | D | |
Class A Common Stock | 11/1/2021 | | S | | 400 (1) | D | $156.66 (8) | 62677 | D | |
Class A Common Stock | 11/1/2021 | | S | | 200 (1) | D | $157.14 | 62477 | D | |
Class A Common Stock | 11/1/2021 | | S | | 900 (1) | D | $159.4289 (9) | 61577 | D | |
Class A Common Stock | 11/1/2021 | | S | | 200 (1) | D | $162.93 (10) | 61377 | D | |
Class A Common Stock | | | | | | | | 75000 | I | By FF Affirm Growth, LLC (11) |
Class A Common Stock | | | | | | | | 1486909 | I | By The Founders Fund Growth, LP (11) |
Class A Common Stock | | | | | | | | 60429 | I | By The Founders Fund Growth Principals Fund, LP (11) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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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 |
Explanation of Responses: |
(1) | The sales reported in this Form 4 were effected pursuant to a Rule 10b5-1 trading plan adopted by the reporting person on September 16, 2021. |
(2) | Represents the weighted average sale price of the shares sold from $150.95 to $151.94 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(3) | Represents the receipt of 56,112 shares of Class A Common Stock pursuant to multiple pro rata distributions effected by Khosla Ventures to its members, including the Reporting Person, for no additional consideration. |
(4) | Represents the weighted average sale price of the shares sold from $152.00 to $152.99 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(5) | Represents the weighted average sale price of the shares sold from $153.03 to $154.01 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(6) | Represents the weighted average sale price of the shares sold from $154.03 to $155.02 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(7) | Represents the weighted average sale price of the shares sold from $155.03 to $155.54 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(8) | Represents the weighted average sale price of the shares sold from $156.14 to $157.00 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(9) | Represents the weighted average sale price of the shares sold from $158.99 to $159.93 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(10) | Represents the weighted average sale price of the shares sold from $162.90 to $162.96 per share. The Reporting Person will provide, upon request by the Commission staff, the Issuer, or a security holder of the Issuer, full information regarding the number of shares sold at each separate price within the range set forth in this footnote. |
(11) | The Reporting Person has shared voting and investment power over the shares held by each of The Founders Fund VI, LP, The Founders Fund VI Principals Fund, LP, The Founders Fund VI Entrepreneurs Fund, LP, The Founders Fund Growth, LP, The Founders Fund Growth Principals Fund, LP and FF Affirm Growth, LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or any other purpose. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Rabois Keith ONE LETTERMAN DRIVE BUILDING D, 5TH FLOOR SAN FRANCISCO, CA 94129 | X |
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Signatures
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/s/ David Ritenour, Attorney-in-Fact | | 11/3/2021 |
**Signature of Reporting Person | Date |
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