SEC Form 4 · accession 0001144204-18-042921
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Mary G Meeker
Director
Period of report
Aug 6, 2018
Accepted (ET)
Aug 8, 2018 · 6:29 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 StockF2 | Aug 6, 2018 | J | 1,000,000 | $0.00 | D | 1,880,540 | I | See Footnote |
| Class A Common StockF4 | Aug 6, 2018 | J | 261,536 | $0.00 | A | 298,786 | I | See Footnote |
| Class A Common StockF4 | Aug 6, 2018 | J | 230,462 | $0.00 | D | 68,324 | I | See Footnote |
| Class A Common StockF7 | Aug 6, 2018 | J | 26,582 | $0.00 | A | 271,575 | D | |
| Class A Common StockF7 | Aug 6, 2018 | J | 1,908 | $0.00 | A | 273,483 | D |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1Represents a pro-rata in-kind distribution of Class A Common Stock of the Issuer by KPCB Digital Growth Fund, LLC ("KPCB Growth"), KPCB DGF Founders Fund, LLC ("KPCB FF"), and KPCB sFund, LLC ("KPCB sFund") without consideration to the respective members of each such entity (the "Fund Distribution").
- F2KPCB Holdings, Inc., as nominee, holds the stock for the account of KPCB Growth, KPCB FF, and KPCB sFund. All shares are held for convenience in the name of "KPCB Holdings, Inc., as nominee" for the accounts of such entities who each exercise their own voting and dispositive power of such shares. The reporting person is a managing member of KPCB DGF Associates, LLC ("DGF Associates"), which is the managing member 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, KPCB FF and KPCB sFund. 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.
- F3Represents a change in the form of ownership from indirect to direct by virtue of the receipt of shares from KPCB Growth in the Fund Distribution by KPCB Growth.
- F4The shares are held directly by DGF Associates. The reporting person is a managing member of DGF Associates and may be deemed to share voting and investment power over the securities held by DGF Associates. 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.
- F5Represents a pro-rata in-kind distribution of Class A Common Stock of the Issuer by DGF Associates without consideration to its members (the "Associates Distribution").
- F6Represents a change in the form of ownership from indirect to direct by virtue of the receipt of shares in the Associates Distribution.
- F7Shares are held directly by the reporting person.
- F8Represents a change in the form of ownership from indirect to direct by virtue of the receipt of shares from KPCB sFund Associates, LLC ("sFund Associates"), of which the reporting person is a member, as part of a pro-rata in-kind distribution of such shares by sFund Associates without consideration to its members.