SEC Form 4 · accession 0000899243-17-015582
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
Jun 2, 2017
Accepted (ET)
Jun 6, 2017 · 8:27 pm EDT
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 |
|---|---|---|---|---|---|---|---|---|
| Class A Common StockF1,F2 | Jun 2, 2017 | C | 10,000,000 | $0.00 | A | 10,000,000 | I | See footnote |
| Class A Common StockF2 | Jun 2, 2017 | J | 5,000,000 | $0.00 | D | 5,000,000 | I | See footnote |
| Class A Common StockF5 | Jun 2, 2017 | J | 454,545 | $0.00 | A | 454,545 | I | See footnote |
| Class A Common StockF5 | Jun 2, 2017 | J | 454,545 | $0.00 | D | 0 | I | See footnote |
| Class A Common StockF6 | Jun 2, 2017 | J | 439,545 | $0.00 | A | 2,109,816 | 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Class B Common StockF7,F2 | — | Jun 2, 2017 | C | 10,000,000 | D | — | — | Class A Common Stock | 10,000,000 | 18,522,780 | I |
Explanation of responses
- F1Pursuant to a conversion exempt under Rule 16b-6(b), shares of Class B Common Stock were automatically converted into shares of Class A Common Stock on a one-for-one basis.
- F2Consists of securities held of record by Khosla Ventures III, LP ("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 securities, and each of KVA III, VK Services and Vinod Khosla may be deemed to have indirect beneficial ownership of such securities. Each Reporting Person disclaims beneficial ownership of such shares except to the extent of his or its pecuniary interest therein.
- F3On June 2, 2017, 5,000,000 shares of Class A Common Stock held by KV III were distributed to the limited partners and general partners of KV III.
- F4On June 2, 2017, 454,545 shares of Class A Common Stock held by KVA III were distributed to the members of KVA III.
- F5Consists of securities held of record by KVA III. Vinod Khosla is the managing member of 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 securities, and each of KVA III, VK Services and Vinod Khosla may be deemed to have indirect beneficial ownership of such securities. Each Reporting Person disclaims beneficial ownership of such shares except to the extent of his or its pecuniary interest therein.
- F6Consists of securities held of record by VK Services. Vinod Khosla is the managing member of VK Services. Each of VK Services and Vinod Khosla may be deemed to possess voting and investment control over such securities, and each of VK Services and Vinod Khosla may be deemed to have indirect beneficial ownership of such securities. Each Reporting Person disclaims beneficial ownership of such shares except to the extent of his or its pecuniary interest therein.
- F7Each 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.