SEC FORM 4 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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X
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*
Octopus Head, Inc

(Last) (First) (Middle)
275 NEW N ROAD
SUITE 3082

(Street)
LONDON X0 N1 7AA

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Expensify, Inc. [ EXFY ]
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)
11/09/2021
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 11/09/2021 J(1) 0(3) A (4) 6,516,640 D(2)
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
1. Name and Address of Reporting Person*
Octopus Head, Inc

(Last) (First) (Middle)
275 NEW N ROAD
SUITE 3082

(Street)
LONDON X0 N1 7AA

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

(Last) (First) (Middle)
275 NEW N ROAD
SUITE 3082

(Street)
LONDON X0 N1 7AA

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

(Last) (First) (Middle)
275 NEW N ROAD
SUITE 3082

(Street)
LONDON X0 N1 7AA

(City) (State) (Zip)
Explanation of Responses:
1. Transaction Code J - Other: Initial Public Offering (IPO)
2. 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, Inc. and the controlling person of 415 Foundation, and in such capacity may be deemed to share voting and investment power over such shares.
3. No securities were acquired or disposed of in this transaction
4. See footnote No. 3.
Remarks:
This filing constitutes a Form 4 exit filing for the Reporting Persons as the Reporting Persons are no longer subject to Section 16 of the Securities Exchange Act of 1934, as amended, as a result of the Issuer's initial public offering
Withold Stankiewicz 11/10/2021
** 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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