SEC Form 4 · accession 0001209191-15-082031

Block, Inc. · XYZ

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

Reporting owner

Roelof Botha

Director · 10% Owner

Period of report

Nov 24, 2015

Accepted (ET)

Nov 24, 2015 · 4:51 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 Stock^F1,F2	Nov 24, 2015	C	13,899,110	—	A	13,899,110	I	By Sequoia Capital U.S. Venture 2010 Fund, LP
Common Stock^F3,F2	Nov 24, 2015	J	13,899,110	—	D	0	I	By Sequoia Capital U.S. Venture 2010 Fund, LP
Common Stock^F1,F2	Nov 24, 2015	C	1,520,930	—	A	1,520,930	I	By Sequoia Capital U.S. Venture 2010 Partners Fund (Q), LP
Common Stock^F3,F2	Nov 24, 2015	J	1,520,930	—	D	0	I	By Sequoia Capital U.S. Venture 2010 Partners Fund (Q), LP
Common Stock^F1,F2	Nov 24, 2015	C	308,270	—	A	308,270	I	By Sequoia Capital U.S. Venture 2010 Partners Fund, LP
Common Stock^F3,F2	Nov 24, 2015	J	308,270	—	D	0	I	By Sequoia Capital U.S. Venture 2010 Partners Fund, LP

Table II — derivative securities

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Series B-2 Preferred Stock^F1,F2	—	Nov 24, 2015	C	13,899,110	D	—	—	Common Stock	13,899,110	0	I
Class B Common Stock^F3,F4,F2	—	Nov 24, 2015	J	13,899,110	A	—	—	Class A Common Stock	13,899,110	13,899,110	I
Series B-2 Preferred Stock^F1,F2	—	Nov 24, 2015	C	1,520,930	D	—	—	Common Stock	1,520,930	0	I
Class B Common Stock^F3,F4,F2	—	Nov 24, 2015	J	1,520,930	A	—	—	Class A Common Stock	1,520,930	1,520,930	I
Series B-2 Preferred Stock^F1,F2	—	Nov 24, 2015	C	308,270	D	—	—	Common Stock	308,270	0	I
Class B Common Stock^F3,F4,F2	—	Nov 24, 2015	J	308,270	A	—	—	Class A Common Stock	308,270	308,270	I

Explanation of responses

F1The Series B-2 Preferred Stock automatically converted into Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering and had no expiration date.
F2Roelof F. Botha is a director of SC US (TTGP), Ltd. ("SC US TTGP"). SC US TTGP is the sole general partner of SC U.S. Venture 2010 Management, L.P., which is the sole general partner of each of Sequoia Capital U.S. Venture 2010 Fund, LP, Sequoia Capital U.S. Venture 2010 Partners Fund, LP and Sequoia Capital U.S. Venture 2010 Partners Fund (Q), LP. By virtue of these relationships, Mr. Botha may be deemed to share voting and dispositive power with respect to the shares held by Sequoia Capital U.S. Venture 2010 Fund, LP, Sequoia Capital U.S. Venture 2010 Partners Fund, LP and Sequoia Capital U.S. Venture 2010 Partners Fund (Q), LP. Mr. Botha disclaims beneficial ownership of these securities except to the extent of his 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.
F3Immediately prior to the closing of the Issuer's initial public offering and following the conversion of each series of the Issuer's convertible preferred stock into Common Stock, each share of Common Stock was reclassified into one share of Class B Common Stock in an exempt transaction pursuant to Rule 16b-7.
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.