Statement of Changes in Beneficial Ownership (4)
March 04 2021 - 4:42PM
Edgar (US Regulatory)
FORM 4
[X]
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
*
Khosla Ventures IV, L.P. |
2. Issuer Name and Ticker or Trading Symbol
Affirm Holdings, Inc.
[
AFRM
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director __X__ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
2128 SAND HILL ROAD |
3. Date of Earliest Transaction
(MM/DD/YYYY)
3/2/2021 |
(Street)
MENLO PARK, CA 94025
(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)
___ Form filed by One Reporting Person
_
X
_ 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 | 3/2/2021 | | J(1) | | 1306094 | D | $0.00 | 5294869 | I | See footnote (2) |
Class A Common Stock | 3/2/2021 | | J(3) | | 83500 | D | $0.00 | 338511 | I | See footnote (4) |
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) | On March 2, 2021, 1,306,094 shares of Class A Common Stock held by Khosla Ventures IV, LP ("KV IV") were distributed to the limited partners and general partners of KV IV in a pro rata distribution for no consideration. Of such distributed shares, 490,470 shares of Class A Common Stock were received by Khosla Ventures Associates IV, LLC ("KVA IV"). |
(2) | Consists of securities held of record by KV IV, of which KVA IV is the general partner. Vinod Khosla is the managing member of VK Services, LLC ("VK Services"), which is the manager of KVA IV. Each of KVA IV, VK Services and Vinod Khosla may be deemed to possess voting and investment control over such securities held by KV IV, and each of KVA IV, VK Services and Vinod Khosla may be deemed to have indirect beneficial ownership of such securities held by KV IV. Each Reporting Person disclaims beneficial ownership of such shares except to the extent of his or its pecuniary interest therein. |
(3) | On March 2, 2021, 83,500 shares of Class A Common Stock held by Khosla Ventures IV (CF), L.P. ("KV IV (CF)"), were distributed to the limited partners and general partners of KV IV (CF) in a pro rata distribution for no consideration. Of such distributed shares, 25,138 shares of Class A Common Stock were received by KVA IV. |
(4) | Consists of securities held of record by KV IV (CF), of which KVA IV is the general partner. Vinod Khosla is the managing member of VK Services, which is the manager of KVA IV. Each of KVA IV, VK Services and Vinod Khosla may be deemed to possess voting and investment control over such securities held by KV IV (CF), and each of KVA IV, VK Services and Vinod Khosla may be deemed to have indirect beneficial ownership of such securities held by KV IV (CF). Each Reporting Person disclaims beneficial ownership of such shares except to the extent of his or its pecuniary interest therein. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Khosla Ventures IV, L.P. 2128 SAND HILL ROAD MENLO PARK, CA 94025 |
| X |
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Khosla Ventures IV (CF), L.P. 2128 SAND HILL ROAD MENLO PARK, CA 94025 |
| X |
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Khosla Ventures Associates IV, LLC 2128 SAND HILL ROAD MENLO PARK, CA 94025 |
| X |
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VK Services, LLC 2128 SAND HILL ROAD MENLO PARK, CA 94025 |
| X |
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KHOSLA VINOD 2128 SAND HILL ROAD MENLO PARK, CA 94025 |
| X |
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Signatures
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/s/ John J. Demeter, as attorney in fact for Vinod Khosla, as Managing Member of VK Services, LLC, in its capacity as Manager of Khosla Ventures Associates IV, LLC, in its capacity as general partner of Khosla Ventures IV, L.P. | | 3/4/2021 |
**Signature of Reporting Person | Date |
/s/John J. Demeter, as attorney in fact for Vinod Khosla, as Managing Member of VK Services, LLC, in its capacity as Manager of Khosla Ventures Associates IV, LLC, in its capacity as general partner of Khosla Ventures IV (CF), L.P. | | 3/4/2021 |
**Signature of Reporting Person | Date |
/s/John J. Demeter, as attorney in fact for Vinod Khosla, as Managing Member of VK Services, LLC, in its capacity as Manager of Khosla Ventures Associates IV, LLC | | 3/4/2021 |
**Signature of Reporting Person | Date |
/s/John J. Demeter, as attorney in fact for Vinod Khosla, as Managing Member of VK Services, LLC | | 3/4/2021 |
**Signature of Reporting Person | Date |
/s/John J. Demeter, as attorney in fact for Vinod Khosla | | 3/4/2021 |
**Signature of Reporting Person | Date |
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