Annual Statement of Changes in Beneficial Ownership (5)
January 31 2019 - 12:31PM
Edgar (US Regulatory)
FORM 5
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
[
X
]
Form 3 Holdings Reported
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
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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
*
OBERTON WILLARD D
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2. Issuer Name
and
Ticker or Trading Symbol
FASTENAL CO [FAST]
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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)
23959 BLACKBERRY ROAD
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2018
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(Street)
WINONA, MN 55987
(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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Amount
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(A) or (D)
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Price
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Common Stock
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1/4/2018
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G
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200
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D
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$0
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363416
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D
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Common Stock
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4/11/2018
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G
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190
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D
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$0
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486519
(1)
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I
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By family trust
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Common Stock
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6/4/2018
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G
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200
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D
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$0
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486319
(1)
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I
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By family trust
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Common Stock
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10/16/2018
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G
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1000
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D
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$0
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485319
(1)
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I
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By family trust
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Common Stock
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10/18/2018
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G
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1000
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D
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$0
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484319
(1)
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I
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By family trust
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Common Stock
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10/24/2018
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G
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1000
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D
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$0
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483319
(1)
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I
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By family trust
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Common Stock
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11/13/2018
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G
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1200
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D
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$0
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482119
(1)
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I
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By family trust
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Common Stock
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11/16/2018
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G
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3000
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D
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$0
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479119
(1)
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I
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By family trust
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Common Stock
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11/19/2018
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G
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1610
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D
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$0
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477509
(1)
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I
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By family trust
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Common Stock
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3
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7097
(2)
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D
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(1)
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These shares are owned in a family trust in which the reporting person and his spouse serve as trustees. This family trust was established on January 11, 2018. The reporting person transferred 363,616 directly owned shares to the family trust on 3/6/18 and 3/26/18, and his spouse transferred 123,293 indirectly owned shares to the family trust on 3/7/18.
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(2)
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Shares maintained in a self-directed IRA.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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OBERTON WILLARD D
23959 BLACKBERRY ROAD
WINONA, MN 55987
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X
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Signatures
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/s/ John Milek, Attorney-in-Fact
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1/31/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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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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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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 control number.
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