SEC Form 4 · accession 0001209191-16-143362
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Francoise Brougher
Officer — Business Lead
Period of report
Sep 28, 2016
Accepted (ET)
Sep 30, 2016 · 5:14 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 | Sep 28, 2016 | C | 57,692 | $0.00 | A | 164,977 | D | |
| Class A Common Stock | Sep 28, 2016 | S | 57,692 | $12.00 | D | 107,285 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Stock Option (right to buy)F3,F4 | $2.904 | Sep 28, 2016 | M | 57,692 | D | — | May 31, 2023 | Class B Common Stock | 57,692 | 2,769,231 | D |
| Class B Common StockF4 | — | Sep 28, 2016 | M | 57,692 | A | — | — | Class A Common Stock | 57,692 | 57,692 | D |
| Class B Common StockF4 | — | Sep 28, 2016 | C | 57,692 | D | — | — | Class A Common Stock | 57,692 | 0 | D |
Explanation of responses
- F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the Reporting Person.
- F2The sale reported on this Form 4 was effected pursuant to a Rule 10b5-1 trading plan adopted by the Reporting Person.
- F325% of the shares subject to the option vested on May 6, 2014, and 1/48 of the shares vest monthly thereafter.
- 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.