Jack Dorsey - 27 May 2022 Form 4 Insider Report for Block, Inc. (XYZ)

Role
Block Head and Chairperson, Director, 10%+ Owner
Signature
/s/ Susan Szotek, Attorney-in-Fact
Issuer symbol
XYZ
Transactions as of
27 May 2022
Net transactions value
$0
Form type
4
Filing time
01 Jun 2022, 17:14:22 UTC
Previous filing
19 May 2021
Next filing
31 Oct 2022
SEC
View on sec.gov

Transactions Table

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Ownership Footnotes
transaction SQ Class A Common Stock Conversion of derivative security $0 +1,000,000 $0.000000 1,000,000 27 May 2022 See Footnote F1, F2

Derivative Securities (e.g., puts, calls, warrants, options, convertible securities)

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Underlying Class Amount Exercise Price Ownership Footnotes
transaction SQ Class B Common Stock Conversion of derivative security $0 -1,000,000 -2.7% $0.000000 35,763,992 27 May 2022 Class A Common Stock 1,000,000 See Footnote F1, F3, F4
holding SQ Class B Common Stock 12,080,574 27 May 2022 Class A Common Stock 12,080,574 See Footnote F3, F5
* An asterisk sign (*) next to the price indicates that the price is likely invalid.

Explanation of Responses:

Id Content
F1 Represents 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, for which the Reporting Person serves as Trustee (the "Dorsey Revocable Trust"). This conversion was effected in connection with the contribution by the Reporting Person of 1,000,000 shares of Class A Common Stock from the Dorsey Revocable Trust to The Jack Dorsey 2022 Annuity Trust, a grantor retained annuity trust for which the Reporting Person serves as Co-Trustee (the "Dorsey Annuity Trust"), which contribution is exempt from Section 16 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), pursuant to Rule 16a-13 under the Exchange Act.
F2 The shares are held of record by the Dorsey Annuity Trust.
F3 Each 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.
F4 The shares are held of record by the Jack Dorsey Revocable Trust u/a/d 12/8/10, for which the Reporting Person serves as a Trustee.
F5 The shares are held of record by Start Small, LLC, for which the Reporting Person is the sole member.