SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
OMB APPROVAL
OMB Number: 3235-0104
Estimated average burden
hours per response: 0.5
1. Name and Address of Reporting Person*
Esperanza Chrysty

(Last) (First) (Middle)
1955 BROADWAY
SUITE 600

(Street)
OAKLAND CA 94612

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
02/16/2023
3. Issuer Name and Ticker or Trading Symbol
Block, Inc. [ SQ ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Interim Counsel Lead
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Class A Common Stock 42,154(1)(2)(3)(4)(5) D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Stock Option (Right to Buy) (6) 10/30/2023 Class B Common Stock(7) 3,150 $3.663 D
Stock Option (Right to Buy) (6) 06/16/2025 Class B Common Stock(7) 20,000 $13.94 D
Stock Option (Right to Buy) (6) 06/16/2025 Class B Common Stock(7) 14,415 $13.94 D
Stock Option (Right to Buy) (8) 04/23/2029 Class A Common Stock 5,513 $71.99 D
Explanation of Responses:
1. Represents 24,107 shares of the Issuer's Class A Common Stock owned and 18,047 shares represented by unvested Restricted Stock Units (RSUs).
2. 207 of the RSUs represent a contingent right to receive one share of the Issuer's Class A Common Stock upon settlement. Of the original grant of an aggregate of 3,308 RSUs, 1/16 of the RSUs vested on July 1, 2019 and 1/16 of the total RSUs vest every three months thereafter.
3. 5,650 of the RSUs represent a contingent right to receive one share of the Issuer's Class A Common Stock upon settlement. Of the original grant of an aggregate of 15,066 RSUs, 1/16 of the RSUs vested on July 1, 2020 and 1/16 of the total RSUs vest every three months thereafter.
4. 1,944 of the RSUs represent a contingent right to receive one share of the Issuer's Class A Common Stock upon settlement. Of the original grant of an aggregate of 3,455 RSUs, 1/16 of the RSUs vested on July 1, 2021 and 1/16 of the total RSUs vest every three months thereafter.
5. 10,246 of the RSUs represent a contingent right to receive one share of the Issuer's Class A Common Stock upon settlement. Of the original grant of an aggregate of 12,610 RSUs, 1/16 of the RSUs vested on July 1, 2022 and 1/16 of the total RSUs vest every three months thereafter.
6. All of the shares subject to this option are fully vested and exercisable as of the date hereof.
7. Each share of Class B Common Stock is convertible into one share of Class A Common Stock a the option of the holder.
8. This option, originally for 8,269 shares, of which 2,756 shares have been exercised, vested as to 1/48th of the shares on May 1, 2019 and 1/48 of the shares vest monthly thereafter.
Remarks:
/s/ Susan Szotek, Attorney-in-Fact 02/17/2023
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.