0001209191-21-003521.txt : 20210113 0001209191-21-003521.hdr.sgml : 20210113 20210113212451 ACCESSION NUMBER: 0001209191-21-003521 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20210113 FILED AS OF DATE: 20210113 DATE AS OF CHANGE: 20210113 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Jiyane Siphelele CENTRAL INDEX KEY: 0001832806 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39888 FILM NUMBER: 21527347 MAIL ADDRESS: STREET 1: C/O AFFIRM HOLDINGS, INC. STREET 2: 650 CALIFORNIA STREET CITY: SAN FRANCISCO STATE: CA ZIP: 94108 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 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2021-01-13 0 0001820953 Affirm Holdings, Inc. AFRM 0001832806 Jiyane Siphelele C/O AFFIRM HOLDINGS, INC. 650 CALIFORNIA STREET SAN FRANCISCO CA 94108 0 1 0 0 Vice President, Controller Class A Common Stock 5000 D Class B Common Stock Class A Common Stock 5000 D Stock Options (right to buy) 1.68 2017-07-05 2026-08-24 Class A Common Stock 14367 D Stock Options (right to buy) 2.04 2027-05-29 Class A Common Stock 12000 D Stock Options (right to buy) 5.39 2028-02-12 Class A Common Stock 66166 D Stock Options (right to buy) 8.80 2029-08-21 Class A Common Stock 30000 D Restricted Stock Units 2026-08-22 Class A Common Stock 8000 D Restricted Stock Units 2027-10-26 Class A Common Stock 60544 D Restricted Stock Units 2027-10-26 Class A Common Stock 34560 D Restricted Stock Units 2027-12-31 Class A Common Stock 21500 D 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 ("Class A Common Stock"). The Class B Common Stock has no expiration date. Stock options vest with respect to 1/24 of the shares of the Issuer's Class A common stock, par value $0.00001 per share ("Class A Common Stock"), underlying the stock option on the one-year anniversary of July 5, 2016, the vesting commencement date of the Reporting Person's first stock option award from the Issuer, and the remaining shares underlying the option vest in equal monthly installments thereafter, in each case subject to continued service with the Issuer. The Reporting Person can elect to exercise the stock options at any time, provided that the shares acquired upon exercise remain subject to the applicable vesting schedule. Stock options vest with respect to the shares of Class A Common Stock underlying the stock option in equal monthly installments for a period of forty-eight months beginning on November 1, 2017, the vesting commencement date, subject to the Reporting Person's continued employment with the Issuer as of each vesting date. The Reporting Person can elect to exercise the stock options at any time, provided that the shares acquired upon exercise remain subject to the applicable vesting schedule. Stock options vest with respect to the shares of Class A Common Stock underlying the stock option in equal monthly installments for a period of forty-eight months beginning on April 1, 2019, the vesting commencement date, subject to the Reporting Person's continued employment with the Issuer as of each vesting date. The Reporting Person can elect to exercise the stock options at any time, provided that the shares acquired upon exercise remain subject to the applicable vesting schedule. Restricted stock units vest with respect to the shares of Class A Common Stock underlying the restricted stock units in equal monthly installments for a period of forty-eight months beginning on April 1, 2019, the vesting commencement date, subject to the Reporting Person's continued employment with the Issuer as of each vesting date. Restricted stock units vest with respect to the shares of Class A Common Stock underlying the restricted stock units in equal monthly installments for a period of forty-eight months beginning on October 1, 2020, the vesting commencement date, subject to the Reporting Person's continued employment with the Issuer as of each vesting date. Restricted stock units vest with respect to the shares of Class A Common Stock underlying the restricted stock units in equal monthly installments for a period of twenty-four months beginning on August 1, 2020, the vesting commencement date, subject to the Reporting Person's continued employment with the Issuer as of each vesting date. Restricted stock units vest with respect to the shares of Class A Common Stock underlying the restricted stock units in equal monthly installments for a period of twenty-four months beginning on January 1, 2021, the vesting commencement date, subject to the Reporting Person's continued employment with the Issuer as of each vesting date. /s/ Sharda Caro del Castillo as Attorney-in-Fact 2021-01-13 EX-24 2 attachment1.htm EX-24 DOCUMENT


POWER OF ATTORNEY
KNOW ALL PERSONS BY THESE PRESENTS that the undersigned hereby constitutes, designates and appoints Sharda Caro del Castillo, David Ritenour and Ryan Chen as such person’s true and lawful attorneys-in-fact and agents, each with full power of substitution and resubstitution and full power to act alone and without the other, for the undersigned and in the undersigned’s name, place and stead, in any and all capacities, to:
(a)          prepare, execute in the undersigned’s name and on the undersigned’s behalf, and submit to the U.S. Securities and Exchange Commission (the “SEC”) a Form ID (or any successor form), including amendments thereto, and any other documents necessary or appropriate to obtain codes and passwords enabling the undersigned to make electronic filings with the SEC of reports required by Section 16(a) or any rule or regulation of the SEC promulgated thereunder;
(b)          execute for and on behalf of the undersigned, in the undersigned’s capacity as an officer and/or director of Affirm Holdings, Inc. (the “Company”), Forms 3, 4, and 5 in accordance with Section 16(a) of the Securities Exchange Act of 1934 and the rules thereunder (or any successor forms);
(c)          do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Form 3, 4, or 5, complete and execute any amendment or amendments thereto, and timely file such form with the SEC and any stock exchange or similar authority; and
(d)          take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact’s discretion.
The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact’s substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming any of the undersigned’s responsibilities to comply with Section 16 of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4, and 5 with respect to the undersigned’s holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact, except that in respect of any person herein appointed as an attorney-in-fact of the undersigned, this Power of Attorney shall be revoked and shall cease to be effective immediately with respect to such person at such time as such person shall no longer be an officer and/or director of the Company or its subsidiaries.

[Signature Page Follows]

IN WITNESS WHEREOF, the undersigned has executed this instrument as of the 12th day of January, 2021

/s/ Siphelele Jiyane
  
Siphelele Jiyane
  










[Signature page to Power of Attorney for Forms 3, 4, and 5]