Affirm (AFRM) Form 3 Affirm / Keith Rabois 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^*

Rabois Keith

(Last) (First) (Middle)

ONE LETTERMAN DRIVE

BUILDING D, 5TH FLOOR

(Street)

SAN FRANCISCO CA 94129

(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)

X	Director	10% Owner
	Officer (give title below)	Other (specify below)

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	2,205,293	I	By The Founders Fund VI, LP(1)
Class A Common Stock	545,294	I	By The Founders Fund VI Principals Fund, LP(1)
Class A Common Stock	27,418	I	By The Founders Fund VI Entrepreneurs Fund, LP(1)
Class A Common Stock	936,909	I	By The Founders Fund Growth, LP(1)
Class A Common Stock	60,429	I	By The Founders Fund Growth Principals Fund, LP(1)

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	(2)	(2)	Class A Common Stock	2,205,293	(2)	I	By The Founders Fund VI, LP
Class B Common Stock	(2)	(2)	Class A Common Stock	545,294	(2)	I	By The Founders Fund VI Principals Fund, LP
Class B Common Stock	(2)	(2)	Class A Common Stock	27,418	(2)	I	By The Founders Fund VI Entrepreneurs Fund, LP
Class B Common Stock	(2)	(2)	Class A Common Stock	936,909	(2)	I	By The Founders Fund Growth, LP
Class B Common Stock	(2)	(2)	Class A Common Stock	60,429	(2)	I	By The Founders Fund Growth Principals Fund, LP

Explanation of Responses:

1. 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 and The Founders Fund Growth Principals Fund, LP. 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.

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.

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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