SEC Form 4 · accession 0001209191-16-148499
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Francoise Brougher
Officer — Business Lead
Period of report
Nov 3, 2016
Accepted (ET)
Nov 4, 2016 · 6:58 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 | Nov 3, 2016 | C | 165,110 | $0.00 | A | 265,243 | D | |
| Class A Common Stock | Nov 3, 2016 | S | 165,110 | $12.00 | D | 100,133 | D | |
| Class A Common Stock | Nov 4, 2016 | C | 7,967 | $0.00 | A | 108,100 | D | |
| Class A Common Stock | Nov 4, 2016 | S | 7,967 | $12.00 | D | 100,133 | 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 | Nov 3, 2016 | M | 165,110 | D | — | May 31, 2023 | Class B Common Stock | 165,110 | 2,604,121 | D |
| Class B Common StockF4 | — | Nov 3, 2016 | M | 165,110 | A | — | — | Class A Common Stock | 165,110 | 165,110 | D |
| Class B Common Stock(F4 | — | Nov 3, 2016 | C | 165,110 | D | — | — | Class A Common Stock | 165,110 | 0 | D |
| Stock Option (right to buy)F3,F4 | $2.904 | Nov 4, 2016 | M | 7,967 | D | — | May 31, 2023 | Class B Common Stock | 7,967 | 2,596,154 | D |
| Class B Common StockF4 | — | Nov 4, 2016 | M | 7,967 | A | — | — | Class A Common Stock | 7,967 | 7,967 | D |
| Class B Common StockF4 | — | Nov 4, 2016 | C | 7,967 | D | — | — | Class A Common Stock | 7,967 | 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.