Affirm (AFRM) Form 3 Affirm / Siphelele Jiyane ownership change

SEC Form 3

FORM 3

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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^*

Jiyane Siphelele

(Last) (First) (Middle)

C/O AFFIRM HOLDINGS, INC.

650 CALIFORNIA STREET

(Street)

SAN FRANCISCO CA 94108

(City) (State) (Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
01/13/2021

3. Issuer Name and Ticker or Trading Symbol
Affirm Holdings, Inc. [ AFRM ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

	Director	10% Owner
X	Officer (give title below)	Other (specify below)
Vice President, Controller

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4)	2. Amount of Securities Beneficially Owned (Instr. 4)	3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	4. Nature of Indirect Beneficial Ownership (Instr. 5)
Class A Common Stock	5,000	D

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4)	2. Date Exercisable and Expiration Date (Month/Day/Year)		3. Title and Amount of Securities Underlying Derivative Security (Instr. 4)		4. Conversion or Exercise Price of Derivative Security	5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
	Date Exercisable	Expiration Date	Title	Amount or Number of Shares
Class B Common Stock	(1)	(1)	Class A Common Stock	5,000	(1)	D
Stock Options (right to buy)	07/05/2017	08/24/2026	Class A Common Stock	14,367	1.68	D
Stock Options (right to buy)	(2)	05/29/2027	Class A Common Stock	12,000	2.04	D
Stock Options (right to buy)	(3)	02/12/2028	Class A Common Stock	66,166	5.39	D
Stock Options (right to buy)	(4)	08/21/2029	Class A Common Stock	30,000	8.8	D
Restricted Stock Units	(5)	08/22/2026	Class A Common Stock	8,000	(5)	D
Restricted Stock Units	(6)	10/26/2027	Class A Common Stock	60,544	(6)	D
Restricted Stock Units	(7)	10/26/2027	Class A Common Stock	34,560	(7)	D
Restricted Stock Units	(8)	12/31/2027	Class A Common Stock	21,500	(8)	D

Explanation of Responses:

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

Remarks:

	/s/ Sharda Caro del Castillo as Attorney-in-Fact	01/13/2021
	** 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 5 (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).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
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