SEC Form 4 · accession 0001209191-15-082021
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
James Morgan McKelvey Jr.
Director · 10% Owner
Period of report
Nov 24, 2015
Accepted (ET)
Nov 24, 2015 · 4:46 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 |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Nov 24, 2015 | J | 5,469,024 | — | D | 0 | D | |
| Common StockF1,F2 | Nov 24, 2015 | J | 21,876,096 | — | D | 0 | 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 StockF1,F3 | — | Nov 24, 2015 | J | 5,469,024 | A | — | — | Class A Common Stock | 5,469,024 | 5,469,024 | D |
| Class B Common StockF1,F3,F2 | — | Nov 24, 2015 | J | 21,876,096 | A | — | — | Class A Common Stock | 21,876,096 | 21,876,096 | I |
Explanation of responses
- 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 James McKelvey, Jr. Revocable Trust dated July 2, 2014, for which the Reporting Person serves as a trustee.
- F3Each 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.