Statement of Changes in Beneficial Ownership (4)
16/11/2021 9:50pm
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
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Philips Jeremy |
2. Issuer Name and Ticker or Trading Symbol
Affirm Holdings, Inc.
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AFRM
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
137 NEWBURY STREET, 8TH FLOOR |
3. Date of Earliest Transaction
(MM/DD/YYYY)
11/12/2021 |
(Street)
BOSTON, MA 02116
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Class A Common Stock | 11/12/2021 | | J(1) | | 2035521 | D | $0.00 | 0 | I | See Footnote (2) |
Class A Common Stock | 11/12/2021 | | J(5) | | 762389 | A | $0.00 | 762389 | D | |
Class A Common Stock | 11/12/2021 | | J(9) | | 12572 | A | $0.00 | 12572 | I | See Footnote (10) |
Class A Common Stock | 11/12/2021 | | J(3) | | 9687 | D | $0.00 | 0 | I | See Footnote (4) |
Class A Common Stock | 11/12/2021 | | J(6) | | 2305 | A | $0.00 | 764694 | D | |
Class A Common Stock | 11/15/2021 | | S | | 10868 | D | $150.00 | 753826 | D | |
Class A Common Stock | 11/15/2021 | | S | | 100 | D | $150.01 | 753726 | D | |
Class A Common Stock | | | | | | | | 74243 | I | See Footnote (7) |
Class A Common Stock | | | | | | | | 757 | I | See Footnote (8) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | Represents a pro-rata distribution, and not a purchase or sale, without additional consideration by Spark Growth Management Partners, LLC ("SGMP") to its members. |
(2) | These shares are held of record by SGMP. The Reporting Person is a managing member of SGMP and may be deemed to share investment, voting and dispositive power over these 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. |
(3) | Represents a pro-rata distribution, and not a purchase or sale, without additional consideration by Spark Growth Management Partners III, LLC ("SGMP III") to its members. |
(4) | These shares are held of record by SGMP III. The Reporting Person is a managing member of SGMP III and may be deemed to share investment, voting and dispositive power over these 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. |
(5) | Represents a change in the form of ownership of the Reporting Person by virtue of receipt of shares as a result of the pro-rata in-kind distribution of Class A Common Stock of the Issuer for no consideration by SGMP. |
(6) | Represents a change in the form of ownership of the Reporting Person by virtue of receipt of shares as a result of the pro-rata in-kind distribution of Class A Common Stock of the Issuer for no consideration by SGMP III. |
(7) | These shares are held of record by Spark Capital Growth Fund III, L.P. ("Spark Growth III"). SGMP III is the general partner of Spark Growth III. The Reporting Person is a managing member of SGMP III and may be deemed to share investment, voting and dispositive power over these 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. |
(8) | These shares are held of record by Spark Capital Growth Founders' Fund III, L.P. ("Spark Growth FF III"). SGMP III is the general partner of Spark Growth FF III. The Reporting Person is a managing member of SGMP III and may be deemed to share investment, voting and dispositive power over these 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. |
(9) | Represents a change in the form of ownership of Spark Capital Partners, LLC ("SCP") by virtue of the receipt of shares in the pro-rata in-kind distribution of Class A Common Stock of the Issuer for no consideration by SGMP. |
(10) | The shares are held by SCP. The Reporting Person is a managing member of SCP and may be deemed to share investment, voting and dispositive power over these shares. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, if any, 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. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Philips Jeremy 137 NEWBURY STREET, 8TH FLOOR BOSTON, MA 02116 | X |
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Signatures
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/s/ Jeremy Philips | | 11/16/2021 |
**Signature of Reporting Person | Date |