SEC Form 4 · accession 0001209191-17-037434

Block, Inc. · XYZ

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

Reporting owner

Director

Period of report

May 31, 2017

Accepted (ET)

Jun 2, 2017 · 6:21 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 Stock^F2	May 31, 2017	C	100,000	$0.00	A	100,000	I	See Footnote
Class A Common Stock^F4,F2	May 31, 2017	S	100,000	$23.22	D	0	I	See Footnote
Class A Common Stock	holding	—	—		—	27,382	D

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Class B Common Stock^F5,F2	—	May 31, 2017	C	100,000	D	—	—	Class A Common Stock	100,000	490,679	I
Class B Common Stock^F5	—	holding	—	—	—	—	—	Class A Common Stock	33,214	33,214	D

F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the LHS 2016 Qualified Annuity Trust - Square (LHS 2016 Trust), for which the Reporting Person serves as trustee.
F2The shares are held of record by the LHS 2016 Trust.
F3The sales reported on this Form 4 were effected pursuant to a Rule 10b5-1 trading plan adopted by the LHS 2016 Trust.
F4The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $23.03 to $23.56 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.
F5Each 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.