0001209191-21-035822.txt : 20210525 0001209191-21-035822.hdr.sgml : 20210525 20210525202544 ACCESSION NUMBER: 0001209191-21-035822 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210521 FILED AS OF DATE: 20210525 DATE AS OF CHANGE: 20210525 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Rabois Keith CENTRAL INDEX KEY: 0001539865 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39888 FILM NUMBER: 21962418 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 doc4.xml FORM 4 SUBMISSION X0306 4 2021-05-21 0 0001820953 Affirm Holdings, Inc. AFRM 0001539865 Rabois Keith ONE LETTERMAN DRIVE, BUILDING D 5TH FLOOR SAN FRANCISCO CA 94129 1 0 0 0 Class A Common Stock 2021-05-21 4 J 0 2205293 0.00 D 0 I By The Founders Fund VI, LP Class A Common Stock 2021-05-21 4 J 0 545294 0.00 D 0 I By The Founders Fund VI Principals Fund, LP Class A Common Stock 2021-05-21 4 J 0 27418 0.00 D 0 I By The Founders Fund VI Entrepreneurs Fund, LP Class A Common Stock 2021-05-21 4 J 0 23969 0.00 A 23969 D Class A Common Stock 1486909 I By The Founders Fund Growth, LP Class A Common Stock 60429 I By The Founders Fund Growth Principals Fund, LP Class A Common Stock 75000 I By FF Affirm Growth, LLC Class B Common Stock 2021-05-21 4 J 0 2205293 0.00 D Class A Common Stock 2205293 0 I By The Founders Fund VI, LP Class B Common Stock 2021-05-21 4 J 0 545294 0.00 D Class A Common Stock 545294 0 I By The Founders Fund VI Principals Fund, LP Class B Common Stock 2021-05-21 4 J 0 27418 0.00 D Class A Common Stock 27418 0 I By The Founders Fund VI Entrepreneurs Fund, LP Class B Common Stock Class A Common Stock 386909 386909 I By The Founders Fund Growth, LP Class B Common Stock Class A Common Stock 60429 60429 I By The Founders Fund Growth Principals Fund, LP Represents a pro rata distribution of shares of Class A common stock, par value $0.00001 per share ("Class A Common Stock") without additional consideration, by the holder to its general partner and limited partners. The Reporting Person did not receive any shares in this distribution. 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. Represents the receipt of shares of Class A Common Stock pursuant to a pro rata distribution effected by TFF V Employees LLC to its members, including the Reporting Person, for no additional consideration. 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. The Class B Common Stock has no expiration date. Represents a pro rata distribution of shares of Class B Common Stock, without additional consideration, by the holder to its general partner and limited partners. The Reporting Person did not receive any shares in this distribution. /s/ Keith Rabois 2021-05-25