SEC Form 4 · accession 0000899243-15-008836

Block, Inc. · XYZ

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owners

Vinod Khosla

10% Owner

Khosla Ventures III, L.P.

10% Owner

VK Services, LLC

10% Owner

Khosla Ventures Associates III, LLC

10% Owner

Period of report

Nov 24, 2015

Accepted (ET)

Nov 24, 2015 · 5:14 pm EST

Rule 10b5-1 plan

unknown — predates the checkbox

Issuer CIK

0001512673

Table I — non-derivative securities

Security	Date	Code	Shares	Price	A/D	Owned after	D/I	Nature of ownership
Common Stock^F1,F4	Nov 24, 2015	C	41,614,640	—	A	41,614,640	I	See footnote
Common Stock^F2,F4	Nov 24, 2015	C	6,321,120	—	A	6,321,120	I	See footnote
Common Stock^F3,F4	Nov 24, 2015	C	2,587,020	—	A	2,587,020	I	See footnote
Common Stock^F5,F4	Nov 24, 2015	J	50,522,780	—	D	0	I	See footnote

Table II — derivative securities

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Series A Preferred Stock^F1,F4	—	Nov 24, 2015	C	41,614,640	D	—	—	Common Stock	41,614,640	0	I
Series B-2 Preferred Stock^F2,F4	—	Nov 24, 2015	C	6,321,120	D	—	—	Common Stock	6,321,120	0	I
Series C Preferred Stock^F3,F4	—	Nov 24, 2015	C	2,587,020	D	—	—	Common Stock	2,587,020	0	I
Class B Common Stock^F5,F6,F4	—	Nov 24, 2015	J	50,522,780	A	—	—	Class A Common Stock	50,522,780	50,522,780	I

Explanation of responses

F1The Series A Preferred Stock automatically converted into Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering and had no expiration date.
F2The Series B-2 Preferred Stock automatically converted into Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering and had no expiration date.
F3The Series C Preferred Stock automatically converted into Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering and had no expiration date.
F4Consists of securities held of record by Khosla Ventures III, L.P. ("KV III"), of which Khosla Ventures Associates III, LLC ("KVA III") is the general partner. Vinod Khosla is the managing member of VK Services, LLC ("VK Services"), which is the manager of KVA III. Each of KVA III, VK Services and Vinod Khosla may be deemed to possess voting and investment control over such shares, and each of KVA III, VK Services and Vinod Khosla may be deemed to have indirect beneficial ownership of such shares. Each Reporting Person disclaims beneficial ownership of such shares except to the extent of his or its pecuniary interest therein.
F5Immediately prior to the closing of the Issuer's initial public offering and following the conversion of each series of the Issuer's convertible preferred stock into Common Stock, each share of Common Stock was reclassified into one share of Class B Common Stock in an exempt transaction pursuant to Rule 16b-7.
F6Each share of Class B Common Stock is convertible into one share of Class A Common Stock at the option of the holder and has no expiration date.