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