SEC Form 4 · accession 0001209191-15-082025

Block, Inc. · XYZ

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

Reporting owner

Director

Period of report

Nov 24, 2015

Accepted (ET)

Nov 24, 2015 · 4:48 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	Nov 24, 2015	J	792,110	—	D	D
Common Stock^F1,F2	Nov 24, 2015	J	209,040	—	D	I	See footnote
Common Stock^F1,F3	Nov 24, 2015	J	90,960	—	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,F4	—	Nov 24, 2015	J	792,110	A	—	—	Class A Common Stock	792,110	792,110	D
Class B Common Stock^F1,F4,F2	—	Nov 24, 2015	J	209,040	A	—	—	Class A Common Stock	209,040	209,040	I
Class B Common Stock^F1,F4,F3	—	Nov 24, 2015	J	90,960	A	—	—	Class A Common Stock	90,960	90,960	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 LHS 2014 Qualified Annuity Trust #1S dated February 13, 2014, for which the Reporting Person serves as trustee.
F3The shares are held of record by the LHS 2015 Qualified Annuity Trust #2S dated March 26, 2015, for which the Reporting Person serves as trustee.
F4Each 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.