SEC Form 4 · accession 0001209191-17-003541

Block, Inc. · XYZ

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owner

Director · 10% Owner

Period of report

Jan 10, 2017

Accepted (ET)

Jan 12, 2017 · 5:42 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 10, 2017	C	90,000	$0.00	A	185,730	D
Class A Common Stock^F3	Jan 10, 2017	S	90,000	$15.13	D	95,730	D

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Class B Common Stock^F4	—	Jan 10, 2017	C	90,000	D	—	—	Class A Common Stock	90,000	2,360,694	D
Class B Common Stock^F4,F5	—	holding	—	—	—	—	—	Class A Common Stock	21,876,096	21,876,096	I

F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the Reporting Person.
F2The sales reported on this Form 4 were effected pursuant to a Rule 10b5-1 trading plan adopted by the Reporting Person.
F3The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $14.73 to $15.44 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.
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.
F5The shares are held of record by the James McKelvey, Jr. Revocable Trust dated July 2, 2014, for which the Reporting Person serves as a Trustee.