SEC Form 4 · accession 0001209191-15-082032
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Mary G Meeker
Director
Period of report
Nov 24, 2015
Accepted (ET)
Nov 24, 2015 · 4:52 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,F2 | Nov 24, 2015 | C | 8,623,410 | — | A | 8,623,410 | I | See footnote |
| Common StockF3,F2 | Nov 24, 2015 | J | 8,623,410 | — | 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series C Preferred StockF1,F2 | — | Nov 24, 2015 | C | 8,623,410 | D | — | — | Common Stock | 8,623,410 | 0 | I |
| Class B Common StockF3,F4,F2 | — | Nov 24, 2015 | J | 8,623,410 | A | — | — | Class A Common Stock | 8,623,410 | 8,623,410 | I |
Explanation of responses
- F1The Series C 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.
- F2The reporting person is a managing member of KPCB DGF Associates, LLC, which is the managing member of KPCB Digital Growth Fund, LLC ("KPCB Growth") and KPCB DGF Founders Fund, LLC ("KPCB FF"). KPCB Holdings, Inc., as nominee, holds the stock for the account 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 and KPCB FF. 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.
- 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.