SEC FORM 3 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*
Octopus Head, Inc

(Last) (First) (Middle)
275 NEW N. RD., STE 3082

(Street)
LONDON X0 N1 7AA

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
11/09/2021
3. Issuer Name and Ticker or Trading Symbol
Expensify, Inc. [ [EXFY] ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 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)
Form filed by One Reporting Person
X 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 6,516,640 D(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
1. Name and Address of Reporting Person*
Octopus Head, Inc

(Last) (First) (Middle)
275 NEW N. RD., STE 3082

(Street)
LONDON X0 N1 7AA

(City) (State) (Zip)
1. Name and Address of Reporting Person*
415 Foundation

(Last) (First) (Middle)
275 NEW N. RD., STE 3082

(Street)
LONDON X0 N1 7AA

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Stankiewicz Witold

(Last) (First) (Middle)
275 NEW N. RD., STE 3082

(Street)
LONDON X0 N1 7AA

(City) (State) (Zip)
Explanation of Responses:
1. 415 Foundation is the sole stockholder of Octopus Head, Inc. and in such capacity may be deemed to share voting and investment power over such shares. Witold Stankiewicz is the sole director of Octopus Head and the controlling person of 415 Foundation, and in such capacity may be deemed to share voting and investment power over such shares.
Remarks:
/s/ Witold Stankiewicz, Director of Octopus Head, Inc. 11/09/2021
/s/ Witold Stankiewicz, Protector of 415 Foundation 11/09/2021
/s/ Witold Stankiewicz 11/09/2021
** 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).
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