SEC Form 5 · accession 0001209191-18-003268
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Lawrence Henry Summers
Director
Period of report
Dec 31, 2017
Accepted (ET)
Jan 11, 2018 · 5:08 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 | Aug 11, 2017 | G | 27,382 | $0.00 | D | 10,651 | D | |
| Class A Common StockF2 | Aug 11, 2017 | G | 27,382 | $0.00 | A | 27,382 | 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 | — | Aug 11, 2017 | G | 201,019 | D | — | — | Class A Common Stock | 201,019 | 0 | D |
| Class B Common StockF3,F2 | — | Aug 11, 2017 | G | 201,019 | A | — | — | Class A Common Stock | 201,019 | 201,019 | I |
| Class B Common StockF3,F4 | — | holding | — | — | — | — | — | Class A Common Stock | 322,874 | 322,874 | I |
Explanation of responses
- F1This transaction involved a gift of shares by the Reporting Person to his LHS 2017 Qualified Annuity Trust - Square, for which the Reporting Person serves as trustee.
- F2The shares are held of record by the LHS 2017 Qualified Annuity Trust - Square.
- 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 LHS 2016 Qualified Annuity Trust - Square, for which the Reporting Person serves as trustee.