SEC Form 4 · accession 0001209191-18-050647
Block, Inc. · XYZ
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
James Morgan McKelvey Jr.
Director
Period of report
Sep 10, 2018
Accepted (ET)
Sep 12, 2018 · 4:45 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 | Sep 10, 2018 | C | 678,000 | $0.00 | A | 750,175 | D | |
| Class A Common Stock | Sep 10, 2018 | G | 678,000 | $0.00 | D | 72,175 | D |
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 StockF2 | — | Sep 10, 2018 | C | 678,000 | D | — | — | Class A Common Stock | 678,000 | 4,522,000 | D |
| Class B Common StockF2,F3 | — | holding | — | — | — | — | — | Class A Common Stock | 13,047,347 | 13,047,347 | I |
Explanation of responses
- F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the Reporting Person.
- F2Each 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.
- F3The shares are held of record by the James McKelvey, Jr. Revocable Trust dated July 2, 2014, for which the Reporting Person serves as a Trustee.