0001820953-21-000036.txt : 20210322
0001820953-21-000036.hdr.sgml : 20210322
20210322212739
ACCESSION NUMBER: 0001820953-21-000036
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210318
FILED AS OF DATE: 20210322
DATE AS OF CHANGE: 20210322
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Levchin Max R
CENTRAL INDEX KEY: 0001539853
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39888
FILM NUMBER: 21762890
MAIL ADDRESS:
STREET 1: C/O YELP! INC.
STREET 2: 706 MISSION ST.
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94103
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
wf-form4_161646284303302.xml
FORM 4
X0306
4
2021-03-18
0
0001820953
Affirm Holdings, Inc.
AFRM
0001539853
Levchin Max R
C/O AFFIRM HOLDINGS, INC.
650 CALIFORNIA STREET
SAN FRANCISCO
CA
94108
1
1
1
0
Chief Executive Officer
Class A Common Stock
2021-03-18
4
C
0
361759
0
A
361759
I
By 2012 MRL Investments LLC
Class A Common Stock
2021-03-18
4
J
0
361759
0
D
0
I
By 2012 MRL Investments LLC
Class A Common Stock
735294
I
By Levchin 2012 Irrevocable Trust
Class B Common Stock
2021-03-18
4
C
0
361759
0
D
Class A Common Stock
361759.0
10352528
I
By 2012 MRL Investments LLC
Class B Common Stock
Class A Common Stock
735294.0
735294
I
By Levchin 2012 Irrevocable Trust
Class B Common Stock
Class A Common Stock
15397650.0
15397650
D
The Reporting Person has sole voting and investment power over the shares held by 2012 MRL Investments LLC.
Represents a pro-rata, in-kind distribution by 2012 MRL Investments LLC to its members (excluding the Reporting Person) without additional consideration.
As joint settlors of the Levchin 2012 Irrevocable Trust, the Reporting Person and his spouse jointly have the right to acquire the shares held by the trust but do not have voting or investment power over such shares. 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 for any other purpose.
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. The Class B Common Stock has no expiration date.
/s/ David Ritenour, Attorney-in-Fact
2021-03-22