SEC Form 4 · accession 0001209191-16-121779

Block, Inc. · XYZ

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

Reporting owner

Director

Period of report

May 17, 2016

Accepted (ET)

May 19, 2016 · 5:23 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 Stock^F2	May 17, 2016	C	108,613	$0.00	A	108,613	I	See footnote
Class A Common Stock^F2	May 17, 2016	G	108,613	$0.00	D	0	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^F3,F2	—	May 17, 2016	C	108,613	D	—	—	Class A Common Stock	108,613	0	I
Class B Common Stock^F3	—	May 18, 2016	G	740,679	D	—	—	Class A Common Stock	740,679	185,000	D
Class B Common Stock^F3,F8	—	May 18, 2016	G	740,679	A	—	—	Class A Common Stock	740,679	740,679	I
Class B Common Stock^F3,F4,F2	—	holding	—	—	—	—	—	Class A Common Stock	108,613	108,613	I
Class B Common Stock^F3,F5,F6	—	holding	—	—	—	—	—	Class A Common Stock	57,818	57,818	I
Class B Common Stock^F3,F7	—	holding	—	—	—	—	—	Class A Common Stock	925,679	925,679	D

F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the LHS 2014 Qualified Annuity Trust #1S dated February 13, 2014 (LHS 2014 #1S), for which the Reporting Person serves as trustee.
F2The shares are held of record by LHS 2014 #1S.
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.
F4Reflects the transfer from LHS 2014 #1S to the Reporting Person as an annuity payment.
F5Reflects the transfer from the LHS 2015 Qualified Annuity Trust #2S dated March 26, 2015 (LHS 2015 #2S), for which the Reporting Person serves as trustee, to the Reporting Person as an annuity payment.
F6The shares are held of record by LHS 2015 #2S.
F7Reflects the transfers from LHS 2014 #1S and LHS 2015 #2S to the Reporting Person as annuity payments.
F8The shares are held of record by the LHS 2016 Qualified Annuity Trust - Square, for which the Reporting Person serves as trustee.