Statement of Changes in Beneficial Ownership (4)
September 16 2021 - 4:49PM
Edgar (US Regulatory)
FORM 4
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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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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
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MATTHEWS NORMAN S |
2. Issuer Name and Ticker or Trading Symbol
Grocery Outlet Holding Corp.
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GO
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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)
C/O GROCERY OUTLET HOLDING CORP.,, 5650 HOLLIS STREET |
3. Date of Earliest Transaction
(MM/DD/YYYY)
9/15/2021 |
(Street)
EMERYVILLE, CA 94608
(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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Common Stock | 9/15/2021 | | A | | 940 (1) | A | $0 | 30962 | D | |
Common Stock | | | | | | | | 123849 | I | By Matthews Family Trust (2) |
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 a grant of 940 fully vested deferred stock units, which resulted from the Reporting Person's earlier election to defer all of his quarterly cash retainer. Such deferred stock units will be settled in a single distribution in shares of the Issuer's common stock upon the Reporting Person's termination of service from the Issuer's Board of Directors. |
(2) | Reflects shares directly held by The Matthews Family 2020 Trust dtd 11/24/2020 of which Mr. Matthews is a Trustee. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
MATTHEWS NORMAN S C/O GROCERY OUTLET HOLDING CORP., 5650 HOLLIS STREET EMERYVILLE, CA 94608 | X |
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Signatures
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/s/ Pamela B. Burke, Pamela B. Burke, as Attorney-in-Fact | | 9/15/2021 |
**Signature of Reporting Person | Date |
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