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
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1. Name and Address of Reporting Person*
AI Palma Holdings LLC

(Last) (First) (Middle)
730 FIFTH AVE, 20TH FL

(Street)
NEW YORK NY 10019

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
11/24/2015
3. Issuer Name and Ticker or Trading Symbol
Square, Inc. [ SQ ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X 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)
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
Class B Common Stock (1) (1) Common Stock 3,999,998 (1) D(2)(3)
1. Name and Address of Reporting Person*
AI Palma Holdings LLC

(Last) (First) (Middle)
730 FIFTH AVE, 20TH FL

(Street)
NEW YORK NY 10019

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
ACCESS INDUSTRIES MANAGEMENT, LLC

(Last) (First) (Middle)
730 FIFTH AVE, 20TH FL

(Street)
NEW YORK NY 10019

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Blavatnik Len

(Last) (First) (Middle)
730 FIFTH AVE, 20TH FL

(Street)
NEW YORK NY 10019

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
Explanation of Responses:
1. The Class B Common Stock is convertible into Class A Common Stock on a 1:1 basis and has no expiration date.
2. The securities reported are held directly by AI Palma Holdings LLC ("Palma") and may be deemed to be indirectly beneficially owned by Access Industries Management, LLC and Len Blavatnik because Access Industries Management, LLC is the manager of Palma, and Mr. Blavatnik controls Access Industries Management, LLC and Palma.
3. Each of the reporting persons (other than Palma) disclaims beneficial ownership of the securities held directly by Palma except to the extent of any pecuniary interest therein, and this Form shall not be construed as an admission that any such reporting person is the beneficial owner of any such securities.
Remarks:
The reporting persons may be deemed to beneficially own more than 10% of the Issuer's Class A Common Stock, which is the class of equity securities registered under Section 12 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), by virtue of the treatment of the securities held by the reporting persons only as being converted into Class A Common Stock for the purpose of computing the reporting persons' percentage ownership of Class A Common Stock. The filing of this Form 3 shall not be deemed an admission that the reporting persons are required to file reports pursuant to Section 16 of the Exchange Act.
/s/ Alejandro Moreno for AI Palma Holdings LLC 11/25/2015
/s/ Alejandro Moreno for Access Industries Management, LLC 11/25/2015
/s/ Alejandro Moreno, as Attorney-in-Fact for Mr. Blavatnik 11/25/2015
** 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).
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