SEC Form 4 · accession 0001209191-16-121760
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Jack Dorsey
Officer — President, CEO & Chairman · Director · 10% Owner
Period of report
Apr 26, 2016
Accepted (ET)
May 19, 2016 · 5:13 pm EDT
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 |
|---|---|---|---|---|---|---|---|---|
| Class A Common StockF2 | Apr 26, 2016 | C | 168,750 | $0.00 | A | 168,750 | I | See footnote |
| Class A Common StockF3,F2 | May 17, 2016 | S | 168,750 | $9.12 | 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 StockF4,F2 | — | Apr 26, 2016 | C | 168,750 | D | — | — | Class A Common Stock | 168,750 | 0 | I |
| Class B Common StockF4,F5 | — | holding | — | — | — | — | — | Class A Common Stock | 61,382,506 | 61,382,506 | I |
| Class B Common StockF4,F6 | — | holding | — | — | — | — | — | Class A Common Stock | 7,952,826 | 7,952,826 | I |
Explanation of responses
- F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by West Studios, LLC.
- F2The 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.
- F3The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $9.00 to $9.35 per share. The Reporting Person undertakes to provide to the Issuer, any security holder of the Issuer, or the staff of the Securities and Exchange Commission, upon request, full information regarding the number of shares sold at each separate price within the range set forth in this footnote.
- 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.
- F5The 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.
- F6The 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.