SEC Form 4 · accession 0000899243-18-030317

Block, Inc. · XYZ

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

Reporting owner

Roelof Botha

Director

Period of report

Dec 3, 2018

Accepted (ET)

Dec 6, 2018 · 7:24 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
Class A Common Stock^F1	Dec 3, 2018	C	2,779,822	$0.00	A	2,779,822	I	By Sequoia Capital U.S. Venture 2010 Fund, LP
Class A Common Stock^F1	Dec 3, 2018	C	304,186	$0.00	A	304,186	I	By Sequoia Capital U.S. Venture 2010 Partners Fund (Q), LP
Class A Common Stock^F1	Dec 3, 2018	C	61,654	$0.00	A	61,654	I	By Sequoia Capital U.S. Venture 2010 Partners Fund, LP
Class A Common Stock^F1	Dec 3, 2018	J	2,779,822	$0.00	D	0	I	By Sequoia Capital U.S. Venture 2010 Fund, LP
Class A Common Stock^F1	Dec 3, 2018	J	304,186	$0.00	D	0	I	By Sequoia Capital U.S. Venture 2010 Partners Fund (Q), LP
Class A Common Stock^F1	Dec 3, 2018	J	61,654	$0.00	D	0	I	By Sequoia Capital U.S. Venture 2010 Partners Fund, LP
Class A Common Stock^F1	Dec 3, 2018	J	179,995	$0.00	D	719,981	I	By Sequoia Capital U.S. Venture 2010-Seed Fund, L.P.
Class A Common Stock	Dec 3, 2018	J	127,231	$0.00	A	127,231	I	By estate planning vehicle
Class A Common Stock	holding	—	—		—	49,322	D
Class A Common Stock^F4	holding	—	—		—	858,081	I	By Sequoia Capital U.S. Growth Fund IV, L.P.
Class A Common Stock^F4	holding	—	—		—	35,657	I	By Sequoia Capital USGF Principals Fund IV, L.P.

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 Stock^F1,F5	—	Dec 3, 2018	C	2,779,822	D	—	—	Class A Common Stock	2,779,822	11,119,288	I
Class B Common Stock^F1,F5	—	Dec 3, 2018	C	304,186	D	—	—	Class A Common Stock	304,186	1,216,744	I
Class B Common Stock^F1,F5	—	Dec 3, 2018	C	61,654	D	—	—	Class A Common Stock	61,654	246,616	I

Explanation of responses

F1SC US (TTGP), Ltd. is the sole general partner of SC U.S. Venture 2010 Management, L.P., which is the sole general partner of each of Sequoia Capital U.S. Venture 2010 Fund, LP, Sequoia Capital U.S. Venture 2010 Partners Fund, LP, Sequoia Capital U.S. Venture 2010 Partners Fund (Q), LP and Sequoia Capital U.S. Venture 2010-Seed Fund, L.P., or collectively, the Venture 2010 Funds. The Reporting Person is a Director of SC US (TTGP), Ltd. The Reporting Person disclaims beneficial ownership of the securities held by the Venture 2010 Funds except to the extent of his pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes.
F2Represents a distribution of Class A Common Stock of the Issuer to partners or members and includes subsequent distributions by general partners or managing members to their respective partners or members.
F3Represents the receipt of shares of Class A Common Stock of the Issuer by virtue of the pro rata in-kind distributions described in footnote (2) above.
F4SC US (TTGP), Ltd. is the general partner of SCGF IV Management, L.P., which is the general partner of Sequoia Capital U.S. Growth Fund IV, L.P. and Sequoia Capital USGF Principals Fund IV, L.P., or collectively, the SC GFIV Funds. The Reporting Person is a Director of SC US (TTGP), Ltd. The Reporting Person disclaims beneficial ownership of the securities held by the SC GFIV Funds except to the extent of his pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes.
F5Each 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.