FORM 4
|
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN 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
|
OMB APPROVAL
|
Estimated average burden hours per response... | 0.5 |
|
|
(Print or Type Responses)
1. Name and Address of Reporting Person *
|
Michalek Libor |
|
2. Issuer Name and Ticker or Trading Symbol Affirm Holdings, Inc. [AFRM]
|
5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director
|
_____ 10% Owner
|
__X__ Officer (give title below)
|
_____ Other (specify below)
|
President, Tech., Risk & Ops
|
|
C/O AFFIRM HOLDINGS, INC., 650 CALIFORNIA STREET |
3. Date of Earliest Transaction (Month/Day/Year) 09/16/2022 |
SAN FRANCISCO, CA 94108 |
4. If Amendment, Date 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 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 |
|
|
|
|
|
|
| 86,953 | D |
|
Class A Common Stock |
|
|
|
|
|
|
| 875,504 | I | Michalek 2007 Trust dated March 21, 2007 (1) |
|
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 1474 (9-02) |
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 Underlying Securities (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
|
Restricted Stock Units | (2) | 09/16/2022 |
| A |
| 112,107 |
|
(3) |
(3) | Class A Common Stock | 112,107.00 |
$
0
| 112,107 | D |
|
Stock Option (Right to Buy) |
$22.30 | 09/16/2022 |
| A |
| 204,750 |
|
(4) | 09/16/2032 | Class A Common Stock | 204,750.00 |
$
0
| 204,750 | D |
|
Reporting Owners
Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Michalek Libor C/O AFFIRM HOLDINGS, INC. 650 CALIFORNIA STREET SAN FRANCISCO, CA 94108 |
X
|
|
President, Tech., Risk & Ops |
|
Signatures
/s/ David Ritenour, Attorney-in-Fact | |
09/20/2022 |
**Signature of Reporting Person | Date |
Explanation of Responses:
* | 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). |
(1) | The shares are held by the Michalek 2007 Family Trust dated March 21, 2007. The Reporting Person and his spouse are trustees of the trust. |
(2) | Each Restricted Stock Unit (RSU) represents a contingent right to receive one share of the Issuer's Class A Common Stock. |
(3) | The RSUs vest in 48 equal monthly installments beginning October 1, 2022, subject to the Reporting Person's continuous service with the Issuer as of each vesting date. This grant has no expiration date. |
(4) | The stock options vest in 48 equal monthly installments beginning October 1, 2022, subject to the Reporting Person's continuous service with the Issuer as of each vesting date. |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number.
|