SEC Form 4 · accession 0001209191-16-151011
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
Nov 15, 2016
Accepted (ET)
Nov 17, 2016 · 7:24 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 |
|---|---|---|---|---|---|---|---|---|
| Class A Common StockF2 | Nov 15, 2016 | C | 57,750 | $0.00 | A | 57,750 | I | See footnote |
| Class A Common StockF3,F2 | Nov 15, 2016 | S | 57,750 | $12.209 | D | 0 | I | See footnote |
| Class A Common StockF5 | Nov 15, 2016 | C | 323,750 | $0.00 | A | 323,750 | I | See footnote |
| Class A Common StockF6,F5 | Nov 15, 2016 | S | 323,750 | $12.1848 | 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 StockF7,F5 | — | Aug 30, 2016 | G | 850,000 | D | — | — | Class A Common Stock | 850,000 | 60,532,506 | I |
| Class B Common StockF7,F2 | — | Aug 30, 2016 | G | 850,000 | A | — | — | Class A Common Stock | 850,000 | 850,000 | I |
| Class B Common StockF7,F2 | — | Nov 15, 2016 | C | 57,750 | D | — | — | Class A Common Stock | 57,750 | 792,250 | I |
| Class B Common StockF7,F5 | — | Nov 15, 2016 | C | 323,750 | D | — | — | Class A Common Stock | 323,750 | 60,208,756 | I |
| Class B Common StockF7,F8 | — | 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 Start Small, LLC.
- F2The shares are held of record by Start Small, LLC, for which the Reporting Person is the sole member.
- F3The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $12.05 to $12.46 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.
- F4Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the Jack Dorsey Revocable Trust u/a/d 12/8/10.
- 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 reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $12.03 to $12.45 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.
- F7Each 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.
- F8The 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.