Statement of Changes in Beneficial Ownership (4)
September 15 2021 - 5:32PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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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
*
BOTHA ROELOF |
2. Issuer Name and Ticker or Trading Symbol
Square, Inc.
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SQ
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
2800 SAND HILL ROAD, SUITE 101 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
7/13/2021 |
(Street)
MENLO PARK, CA 94025
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Class A Common Stock | 7/13/2021 | | A | | 11388 | A | (1) | 11388 | I | Sequoia Capital U.S. Venture Fund XV, L.P. (2) |
Class A Common Stock | 7/13/2021 | | A | | 479 | A | (1) | 479 | I | Sequoia Capital U.S. Venture Partners Fund XV (Q), L.P. (2) |
Class A Common Stock | 7/13/2021 | | A | | 171 | A | (1) | 171 | I | Sequoia Capital U.S. Venture Partners Fund XV, L.P. (2) |
Class A Common Stock | 7/13/2021 | | A | | 1750 | A | (1) | 1750 | I | Sequoia Capital U.S. Venture XV Principals Fund, L.P. (2) |
Class A Common Stock | | | | | | | | 12206 | D | |
Class A Common Stock | | | | | | | | 1862 | I | Sequoia Capital U.S. Growth Fund IV, L.P. (3) |
Class A Common Stock | | | | | | | | 77 | I | Sequoia Capital USGF Principals Fund IV, L.P. (3) |
Class A Common Stock | | | | | | | | 684741 | I | By estate planning vehicle |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | Represents shares of Class A Common Stock of the Issuer received on July 13, 2021 as transaction consideration pursuant to the Agreement and Plan of Merger, dated June 9, 2021, between the Issuer, Speramus, Inc. and the other parties thereto. |
(2) | SC US (TTGP), Ltd. is the general partner of SC U.S. Venture XV Management, L.P., which is the general partner of Sequoia Capital U.S. Venture Fund XV, L.P., Sequoia Capital U.S. Venture Partners Fund XV (Q), L.P., Sequoia Capital U.S. Venture Partners Fund XV, L.P. and Sequoia Capital U.S. Venture XV Principals Fund, L.P., or collectively, the SC USV XV Funds. The Reporting Person is a Director of SC US (TTGP), Ltd. The Reporting Person disclaims beneficial ownership of the securities held by the SC USV XV Funds except to the extent of his pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
(3) | SC US (TTGP), Ltd. is the general partner of SCGF IV Management, L.P., which is the general partner of Sequoia Capital U.S. Growth Fund IV, L.P. and Sequoia Capital USGF Principals Fund IV, L.P., or collectively, the SC GFIV Funds. The Reporting Person is a Director of SC US (TTGP), Ltd. The Reporting Person disclaims beneficial ownership of the securities held by the SC GFIV Funds except to the extent of his pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
BOTHA ROELOF 2800 SAND HILL ROAD, SUITE 101 MENLO PARK, CA 94025 | X |
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Signatures
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/s/ Jung Yeon Son, Attorney-in-Fact for Roelof Botha | | 9/15/2021 |
**Signature of Reporting Person | Date |
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