SEC Form 4 · accession 0001209191-18-051956

Block, Inc. · XYZ

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

Reporting owner

Officer — Chief Financial Officer

Period of report

Sep 19, 2018

Accepted (ET)

Sep 21, 2018 · 5:33 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	Sep 19, 2018	C	449,320	$0.00	A	449,320	I	See Footnote
Class A Common Stock^F2	Sep 19, 2018	G	449,320	$0.00	D	0	I	See Footnote
Class A Common Stock	holding	—	—		—	361,725	D

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Class B Common Stock^F3,F2	—	Sep 19, 2018	C	449,320	D	—	—	Class A Common Stock	449,320	99,133	I
Class B Common Stock^F3,F2	—	Sep 19, 2018	G	99,133	D	—	—	Class A Common Stock	99,133	0	I
Class B Common Stock^F3,F4	—	Sep 19, 2018	G	99,133	A	—	—	Class A Common Stock	99,133	399,449	I

F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by The Sarah Friar 2015 GRAT dated August 6, 2015 (2015 GRAT), for which the Reporting Person serves as a trustee.
F2The shares are held of record by the 2015 GRAT.
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 David Riley and Sarah Friar Revocable Trust dated August 11, 2006 (Revocable Trust), for which the Reporting Person serves as a trustee. The Reporting Person has sole dispositive power and voting control over the shares of the Issuer held by the Revocable Trust.