SEC Form 4 · accession 0001144204-16-103299
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Mary G Meeker
Director
Period of report
May 17, 2016
Accepted (ET)
May 18, 2016 · 12:14 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 | May 17, 2016 | C | 8,623,410 | $0.00 | A | 8,623,410 | 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 StockF2,F3,F1 | — | May 17, 2016 | C | 8,623,410 | D | — | — | Class A Common Stock | 8,623,410 | 0 | I |
Explanation of responses
- F1The reporting person is a managing member of KPCB DGF Associates, LLC, which is the managing member of KPCB Digital Growth Fund, LLC ("KPCB Growth") and KPCB DGF Founders Fund, LLC ("KPCB FF"). KPCB Holdings, Inc., as nominee, holds the stock for the account of KPCB Growth and KPCB FF. The reporting person may be deemed to share voting and investment power over the securities held by KPCB Growth and KPCB FF. The reporting person disclaims beneficial ownership over such securities except to the extent of her 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.
- F2Each 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.
- F3The holder elected to convert the shares of Class B Common Stock into Class A Common Stock.