SEC Form 4 · accession 0001209191-17-003543
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
Jan 10, 2017
Accepted (ET)
Jan 12, 2017 · 5:45 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 | Jan 10, 2017 | C | 57,750 | $0.00 | A | 57,750 | I | See footnote |
| Class A Common StockF4,F2 | Jan 10, 2017 | S | 57,750 | $15.28 | D | 0 | I | See footnote |
| Class A Common StockF6 | Jan 10, 2017 | C | 323,750 | $0.00 | A | 323,750 | I | See footnote |
| Class A Common StockF8,F6 | Jan 10, 2017 | S | 323,750 | $15.15 | 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 StockF9,F2 | — | Jan 10, 2017 | C | 57,750 | D | — | — | Class A Common Stock | 57,750 | 561,250 | I |
| Class B Common StockF9,F6 | — | Jan 10, 2017 | C | 323,750 | D | — | — | Class A Common Stock | 323,750 | 58,913,756 | I |
| Class B Common StockF9,F10 | — | 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 for which the Reporting Person is the sole member.
- F10The 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.
- F2The shares are held of record by Start Small, LLC.
- F3The sales reported on this Form 4 were effected pursuant to a Rule 10b5-1 trading plan adopted by Start Small, LLC.
- F4The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $15.06 to $15.46 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.
- 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, for which the Reporting Person serves as Trustee.
- F6The shares are held of record by the Jack Dorsey Revocable Trust u/a/d 12/8/10.
- F7The sales reported on this Form 4 were effected pursuant to a Rule 10b5-1 trading plan adopted by the Jack Dorsey Revocable Trust u/a/d 12/8/10.
- F8The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $14.82 to $15.48 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.
- F9Each 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.