SEC Form 4 · accession 0001209191-16-156967
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
Dec 27, 2016
Accepted (ET)
Dec 29, 2016 · 10:31 am 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 | Dec 27, 2016 | C | 57,750 | $0.00 | A | 57,750 | I | See footnote |
| Class A Common StockF4,F2 | Dec 27, 2016 | S | 57,750 | $14.0935 | D | 0 | I | See footnote |
| Class A Common StockF6 | Dec 27, 2016 | C | 323,750 | $0.00 | A | 323,750 | I | See footnote |
| Class A Common StockF7,F6 | Dec 27, 2016 | S | 323,750 | $14.0907 | 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 StockF8,F2 | — | Dec 27, 2016 | C | 57,750 | D | — | — | Class A Common Stock | 57,750 | 619,000 | I |
| Class B Common StockF8,F6 | — | Dec 27, 2016 | C | 323,750 | D | — | — | Class A Common Stock | 323,750 | 59,237,506 | I |
| Class B Common StockF8,F9 | — | 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 sales reported on this Form 4 were effected pursuant to a Rule 10b5-1 trading plan adopted by the Reporting Person.
- F4The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $14.00 to $14.24 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.
- F5Represents 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.
- F6The 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.
- F7The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $14.00 to $14.24 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.
- F8Each 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.
- F9The 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.