SEC Form 4 · accession 0001209191-17-003239
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Lawrence Henry Summers
Director
Period of report
Jan 6, 2017
Accepted (ET)
Jan 10, 2017 · 5:27 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 Stock | Jan 6, 2017 | C | 23,125 | $0.00 | A | 50,507 | D | |
| Class A Common Stock | Jan 6, 2017 | S | 23,125 | $15.00 | D | 27,382 | D |
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 StockF2 | — | Jan 6, 2017 | C | 23,125 | D | — | — | Class A Common Stock | 23,125 | 0 | D |
| Class B Common StockF2,F3 | — | holding | — | — | — | — | — | Class A Common Stock | 57,818 | 57,818 | I |
| Class B Common StockF2,F4 | — | holding | — | — | — | — | — | Class A Common Stock | 740,679 | 740,679 | I |
Explanation of responses
- F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the Reporting Person.
- F2Each 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.
- F3The shares are held of record by the LHS 2015 Qualified Annuity Trust #2S dated March 26, 2015, for which the Reporting Person serves as trustee.
- F4The shares are held of record by the LHS 2016 Qualified Annuity Trust - Square, for which the Reporting Person serves as trustee.