0000899243-21-009844.txt : 20210304
0000899243-21-009844.hdr.sgml : 20210304
20210304164147
ACCESSION NUMBER: 0000899243-21-009844
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210302
FILED AS OF DATE: 20210304
DATE AS OF CHANGE: 20210304
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: KHOSLA VINOD
CENTRAL INDEX KEY: 0001032453
STATE OF INCORPORATION: CA
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39888
FILM NUMBER: 21714711
MAIL ADDRESS:
STREET 1: 2128 SAND HILL RD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: VK Services, LLC
CENTRAL INDEX KEY: 0001501927
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39888
FILM NUMBER: 21714712
BUSINESS ADDRESS:
STREET 1: 2128 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: (650) 376-8510
MAIL ADDRESS:
STREET 1: 2128 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Khosla Ventures IV, L.P.
CENTRAL INDEX KEY: 0001521016
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39888
FILM NUMBER: 21714715
BUSINESS ADDRESS:
STREET 1: 3000 SAND HILL ROAD
STREET 2: SUITE 190
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: 650-376-8500
MAIL ADDRESS:
STREET 1: 3000 SAND HILL ROAD
STREET 2: SUITE 190
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Khosla Ventures Associates IV, LLC
CENTRAL INDEX KEY: 0001685549
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39888
FILM NUMBER: 21714713
BUSINESS ADDRESS:
STREET 1: 2128 SAND HILL RD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: 650-376-8500
MAIL ADDRESS:
STREET 1: 2128 SAND HILL RD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Khosla Ventures IV (CF), L.P.
CENTRAL INDEX KEY: 0001685550
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39888
FILM NUMBER: 21714714
BUSINESS ADDRESS:
STREET 1: 2128 SAND HILL RD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: 650-376-8500
MAIL ADDRESS:
STREET 1: 2128 SAND HILL RD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Affirm Holdings, Inc.
CENTRAL INDEX KEY: 0001820953
STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-BUSINESS SERVICES, NEC [7389]
IRS NUMBER: 842224323
STATE OF INCORPORATION: DE
FISCAL YEAR END: 0630
BUSINESS ADDRESS:
STREET 1: 650 CALIFORNIA STREET
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94108
BUSINESS PHONE: (415) 722-8633
MAIL ADDRESS:
STREET 1: 650 CALIFORNIA STREET
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94108
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2021-03-02
1
0001820953
Affirm Holdings, Inc.
AFRM
0001521016
Khosla Ventures IV, L.P.
2128 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001685550
Khosla Ventures IV (CF), L.P.
2128 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001685549
Khosla Ventures Associates IV, LLC
2128 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001501927
VK Services, LLC
2128 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001032453
KHOSLA VINOD
2128 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
Class A Common Stock
2021-03-02
4
J
0
1306094
0.00
D
5294869
I
See footnote
Class A Common Stock
2021-03-02
4
J
0
83500
0.00
D
338511
I
See footnote
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").
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.
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.
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.
/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.
2021-03-04
/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.
2021-03-04
/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
2021-03-04
/s/John J. Demeter, as attorney in fact for Vinod Khosla, as Managing Member of VK Services, LLC
2021-03-04
/s/John J. Demeter, as attorney in fact for Vinod Khosla
2021-03-04