SEC Form 4 · accession 0001209191-15-082010

Block, Inc. · XYZ

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

Reporting owner

Officer — President, CEO & Chairman · Director · 10% Owner

Period of report

Nov 24, 2015

Accepted (ET)

Nov 24, 2015 · 4:40 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	D/I	Nature of ownership
Common Stock^F1,F2	Nov 24, 2015	J	61,382,506	—	D	I	See footnote
Common Stock^F1,F3	Nov 24, 2015	J	7,952,826	—	D	I	See footnote
Common Stock^F1,F4	Nov 24, 2015	J	168,750	—	D	I	See footnote

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Class B Common Stock^F1,F5,F2	—	Nov 24, 2015	J	61,382,506	A	—	—	Class A Common Stock	61,382,506	61,382,506	I
Class B Common Stock^F1,F5,F3	—	Nov 24, 2015	J	7,952,826	A	—	—	Class A Common Stock	7,952,826	7,952,826	I
Class B Common Stock^F1,F5,F4	—	Nov 24, 2015	J	168,750	A	—	—	Class A Common Stock	168,750	168,750	I

F1Immediately prior to the closing of the Issuer's initial public offering, each share of Common Stock was reclassified into one share of Class B Common Stock in an exempt transaction pursuant to Rule 16b-7.
F2The shares are held of record by the Jack Dorsey Revocable Trust u/a/d 12/8/10, for which the Reporting Person serves as trustee.
F3The shares are held of record by the Jack Dorsey Remainder Trust u/a/d 6/23/10, for which the Reporting Person serves as trustee.
F4The shares are held of record by West Studios, LLC for which the Reporting Person is a managing member and shares voting and dispositive power. The Reporting Person disclaims beneficial ownership of such shares except to the extent of his pecuniary interest therein.
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.