SEC Form 4 · accession 0001209191-18-054901

Block, Inc. · XYZ

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

Reporting owner

Jack Dorsey

Officer — President, CEO & Chairman · Director · 10% Owner

Period of report

Oct 10, 2018

Accepted (ET)

Oct 12, 2018 · 5:32 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	Oct 10, 2018	C	103,035	$0.00	A	103,035	I	See Footnote
Class A Common Stock^F4,F2	Oct 10, 2018	S	8,561	$77.57	D	94,474	I	See Footnote
Class A Common Stock^F5,F2	Oct 10, 2018	S	19,806	$78.47	D	74,668	I	See Footnote
Class A Common Stock^F6,F2	Oct 10, 2018	S	26,726	$79.38	D	47,942	I	See Footnote
Class A Common Stock^F7,F2	Oct 10, 2018	S	15,400	$80.44	D	32,542	I	See Footnote
Class A Common Stock^F8,F2	Oct 10, 2018	S	13,839	$81.35	D	18,703	I	See Footnote
Class A Common Stock^F9,F2	Oct 10, 2018	S	3,400	$82.32	D	15,303	I	See Footnote
Class A Common Stock^F10,F2	Oct 10, 2018	S	4,800	$83.60	D	10,503	I	See Footnote
Class A Common Stock^F11,F2	Oct 10, 2018	S	5,303	$84.65	D	5,200	I	See Footnote
Class A Common Stock^F12,F2	Oct 10, 2018	S	2,800	$85.67	D	2,400	I	See Footnote
Class A Common Stock^F13,F2	Oct 10, 2018	S	2,400	$86.67	D	0	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 Stock^F14,F2	—	Oct 10, 2018	C	103,035	D	—	—	Class A Common Stock	103,035	54,509,131	I
Class B Common Stock^F14,F15	—	holding	—	—	—	—	—	Class A Common Stock	7,752,826	7,752,826	I

Explanation of responses

F1Represents the conversion of Class B Common Stock into Class A Common Stock held of record by the Jack Dorsey Revocable Trust u/a/d 12/8/10 (Dorsey Revocable Trust), for which the Reporting Person serves as Trustee.
F10The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $83.16 to $84.06 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.
F11The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $84.17 to $85.02 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.
F12The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $85.20 to $86.15 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.
F13The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $86.30 to $86.83 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.
F14Each 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.
F15The shares are held of record by the Jack Dorsey Remainder Trust u/a/d 6/23/10, for which the Reporting Person serves as Trustee.
F2The shares are held of record by the Dorsey Revocable Trust.
F3The sales reported on this Form 4 were effected pursuant to a Rule 10b5-1 trading plan adopted by the Dorsey Revocable Trust.
F4The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $76.92 to $77.91 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.
F5The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $77.92 to $78.89 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.
F6The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $78.92 to $79.91 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.
F7The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $79.92 to $80.91 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.
F8The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $80.92 to $81.89 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.
F9The reported price in Column 4 is a weighted average sale price. These shares were sold in multiple transactions at prices ranging from $81.94 to $82.92 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.