SEC Form 4 · accession 0001209191-18-044070
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Lawrence Henry Summers
Director
Period of report
Jul 24, 2018
Accepted (ET)
Jul 26, 2018 · 5:08 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 | Jul 24, 2018 | C | 322,874 | $0.00 | A | 322,874 | I | See Footnote |
| Class A Common StockF2 | Jul 25, 2018 | G | 322,874 | $0.00 | D | 0 | I | See Footnote |
| Class A Common Stock | holding | — | — | — | 14,441 | D | ||
| Class A Common StockF3 | holding | — | — | — | 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 StockF4,F2 | — | Jul 24, 2018 | C | 322,874 | D | — | — | Class A Common Stock | 322,874 | 0 | I |
| Class B Common StockF4,F3 | — | holding | — | — | — | — | — | Class A Common Stock | 201,019 | 201,019 | I |
Explanation of responses
- 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 shares are held of record by LHS 2017 Qualified Annuity Trust - Square, for which the Reporting Person serves as trustee.
- F4Each 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.