SEC Form 4 · accession 0001209191-17-007836
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
Feb 1, 2017
Accepted (ET)
Feb 3, 2017 · 6:49 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 | Feb 1, 2017 | C | 7,200 | $0.00 | A | 7,200 | I | See Footnote |
| Class A Common StockF2 | Feb 1, 2017 | G | 7,200 | $0.00 | 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 StockF3,F2 | — | Feb 1, 2017 | C | 7,200 | D | — | — | Class A Common Stock | 7,200 | 58,582,806 | I |
| Class B Common StockF3,F4 | — | holding | — | — | — | — | — | Class A Common Stock | 7,952,826 | 7,952,826 | I |
| Class B Common StockF3,F5 | — | holding | — | — | — | — | — | Class A Common Stock | 503,500 | 503,500 | I |
Explanation of responses
- F1Represents 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.
- F2The shares are held of record by the Jack Dorsey Revocable Trust u/a/d 12/8/10.
- F3Each 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.
- F4The 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.
- F5The shares are held of record by Start Small, LLC, for which the Reporting Person is the sole member.