SEC Form 4 · accession 0001209191-17-028247
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Lawrence Henry Summers
Director
Period of report
Apr 24, 2017
Accepted (ET)
Apr 26, 2017 · 6:07 pm EDT
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 | Apr 24, 2017 | C | 24,604 | $0.00 | A | 24,604 | I | See Footnote |
| Class A Common StockF2 | Apr 24, 2017 | G | 24,604 | $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 | — | Apr 24, 2017 | C | 24,604 | D | — | — | Class A Common Stock | 24,604 | 0 | I |
| Class B Common StockF3,F4,F2 | — | holding | — | — | — | — | — | Class A Common Stock | 24,604 | 24,604 | I |
| Class B Common StockF3,F4 | — | holding | — | — | — | — | — | Class A Common Stock | 33,214 | 33,214 | D |
| Class B Common StockF3,F5 | — | 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 LHS 2015 Qualified Annuity Trust #2S dated March 26, 2015 (LHS 2015 #2S), for which the Reporting Person serves as trustee.
- F2The shares are held of record by LHS 2015 #2S.
- 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.
- F4Reflects the transfer from LHS 2015 #2S to the Reporting Person as an annuity payment.
- F5The shares are held of record by the LHS 2016 Qualified Annuity Trust - Square, for which the Reporting Person serves as trustee.