SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
Founders Fund V Management, LLC

(Last) (First) (Middle)
ONE LETTERMAN DRIVE, BUILDING D
5TH FLOOR

(Street)
SAN FRANCISCO CA 94129

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Affirm Holdings, Inc. [ AFRM ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
01/15/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Class A Common Stock 01/15/2021 P 75,000 A $49 75,000 I By Fund(1)
Class A Common Stock 01/15/2021 C 550,000 A (2) 1,486,909 I By Fund(3)
Class A Common Stock 3,994,807 I By Fund(4)
Class A Common Stock 1,074,604 I By Fund(5)
Class A Common Stock 56,539 I By Fund(6)
Class A Common Stock 2,205,293 I By Fund(7)
Class A Common Stock 545,294 I By Fund(8)
Class A Common Stock 27,418 I By Fund(9)
Class A Common Stock 60,429 I By Fund(10)
Class A Common Stock 142,857 I By LLC(11)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction 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 (Month/Day/Year) 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: 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
Class B Common Stock (2) 01/15/2021 C 550,000 (2) (2) Class A Common Stock 550,000 $0.00 386,909 I By Fund(3)
Class B Common Stock (2) (2) (2) Class A Common Stock 3,994,807 3,994,807 I By Fund(4)
Class B Common Stock (2) (2) (2) Class A Common Stock 1,074,604 1,074,604 I By Fund(5)
Class B Common Stock (2) (2) (2) Class A Common Stock 56,539 56,539 I By Fund(6)
Class B Common Stock (2) (2) (2) Class A Common Stock 2,205,293 2,205,293 I By Fund(7)
Class B Common Stock (2) (2) (2) Class A Common Stock 545,294 545,294 I By Fund(8)
Class B Common Stock (2) (2) (2) Class A Common Stock 27,418 27,418 I By Fund(9)
Class B Common Stock (2) (2) (2) Class A Common Stock 60,429 60,429 I By Fund(10)
Class B Common Stock (2) (2) (2) Class A Common Stock 142,857 142,857 I By LLC(11)
1. Name and Address of Reporting Person*
Founders Fund V Management, LLC

(Last) (First) (Middle)
ONE LETTERMAN DRIVE, BUILDING D
5TH FLOOR

(Street)
SAN FRANCISCO CA 94129

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Founders Fund V Entrepreneurs Fund, LP

(Last) (First) (Middle)
ONE LETTERMAN DRIVE, BUILDING D
5TH FLOOR

(Street)
SAN FRANCISCO CA 94129

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Founders Fund V Principals Fund, LP

(Last) (First) (Middle)
ONE LETTERMAN DRIVE, BUILDING D
5TH FLOOR

(Street)
SAN FRANCISCO CA 94129

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Founders Fund V, LP

(Last) (First) (Middle)
ONE LETTERMAN DRIVE, BUILDING D
5TH FLOOR

(Street)
SAN FRANCISCO CA 94129

(City) (State) (Zip)
1. Name and Address of Reporting Person*
THIEL PETER

(Last) (First) (Middle)
C/O THE FOUNDERS FUND
ONE LETTERMAN DRIVE, BUILDING D, 5TH FLO

(Street)
SAN FRANCISCO CA 94129

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Singerman Brian Aaron

(Last) (First) (Middle)
C/O THE FOUNDERS FUND
ONE LETTERMAN DRIVE, BUILDING D, 5TH FLO

(Street)
SAN FRANCISCO CA 94129

(City) (State) (Zip)
Explanation of Responses:
1. Shares held by FF Affirm Growth, LLC ("FF-Affirm"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-Affirm and, accordingly, may be deemed to beneficially own the shares held by FF-Affirm. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer, files separate Section 16 reports, and reported this purchase on a Form 4 filed on January 15, 2021.
2. 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.
3. Shares held by The Founders Fund Growth, LP ("FF-G"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-G and, accordingly, may be deemed to beneficially own the shares held by FF-G. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports.
4. Shares held by The Founders Fund V, LP ("FF-V"). The Founders Fund V Management, LLC ("FF-VM") is the general partner of FF-V and may be deemed to beneficially own the shares held by FF-V. Peter Thiel and Brian Singerman have shared voting and investment power over the shares held by FF-V and, accordingly, may be deemed to beneficially own the shares held by FF-V. Each of FF-VM, Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his or its respective pecuniary interest therein.
5. Shares held by The Founders Fund V Principals Fund, LP ("FF-VP"). FF-VM is the general partner of FF-VP and may be deemed to beneficially own the shares held by FF-VP. Peter Thiel and Brian Singerman have shared voting and investment power over the shares held by FF-VP and, accordingly, may be deemed to beneficially own the shares held by FF-VP. Each of FF-VM, Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his or its respective pecuniary interest therein.
6. Shares held by The Founders Fund V Entrepreneurs Fund, LP ("FF-VE"). FF-VM is the general partner of FF-VE and may be deemed to beneficially own the shares held by FF-VE. Peter Thiel and Brian Singerman have shared voting and investment power over the shares held by FF-VE and, accordingly, may be deemed to beneficially own the shares held by FF-VE. Each of FF-VM, Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his or its respective pecuniary interest therein.
7. Shares held by The Founders Fund VI, LP ("FF-VI"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-VI and, accordingly, may be deemed to beneficially own the shares held by FF-VI. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports.
8. Shares held by The Founders Fund VI Principals Fund, LP ("FF-VIP"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-VIP and, accordingly, may be deemed to beneficially own the shares held by FF-VIP. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports.
9. Shares held by The Founders Fund VI Entrepreneurs Fund, LP ("FF-VIE"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-VIE and, accordingly, may be deemed to beneficially own the shares held by FF-VIE. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports.
10. Shares held by The Founders Fund Growth Principals Fund, LP ("FF-GP"). Peter Thiel, Brian Singerman and Keith Rabois have shared voting and investment power over the shares held by FF-GP and, accordingly, may be deemed to beneficially own the shares held by FF-GP. Each of Mr. Thiel and Mr. Singerman disclaims beneficial ownership in these shares except to the extent of his respective pecuniary interest therein. Mr. Rabois is a director of the Issuer and files separate Section 16 reports.
11. Shares held by Rivendell Investments 3 LLC. Peter Thiel is the beneficial owner of Rivendell Investments 3 LLC and has sole voting and investment power over the shares held by Rivendell Investments 3 LLC.
Remarks:
The Founders Fund Management V LLC, By /s/ Brian Singerman, Managing Member 01/20/2021
The Founders Fund V Entrepreneurs Fund, LP, By The Founders Fund Management V LLC, General Partner, By /s/ Brian Singerman, Managing Member 01/20/2021
The Founders Fund V Principals Fund, LP, By The Founders Fund Management V LLC, General Partner, By /s/ Brian Singerman, Managing Member 01/20/2021
The Founders Fund V, LP, By The Founders Fund Management V LLC, General Partner, By /s/ Brian Singerman, Managing Member 01/20/2021
/s/ Peter Thiel 01/20/2021
/s/ Brian A. Singerman 01/20/2021
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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