SEC FORM
5
SEC Form 5
| FORM 5 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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: |
3235-0362 |
| Estimated average burden |
| hours per response: |
1.0 |
|
|
 |
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
|
Form 3 Holdings Reported. |
|
Form 4 Transactions Reported. |
1. Name and Address of Reporting Person*
| 4440 ROSEWOOD DRIVE, BUILDING 4 |
|
(Street)
|
2. Issuer Name and Ticker or Trading Symbol
ROSS STORES INC
[ ROST ]
|
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
|
President, Chief Dev. Officer
|
|
3. Statement for Issuer's Fiscal Year Ended
(Month/Day/Year)
02/02/2013
|
4. 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 Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
|
2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
|
4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
|
5.
Amount of Securities Beneficially Owned at end of Issuer's Fiscal Year (Instr.
3 and 4)
|
6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
|
7. Nature of Indirect Beneficial Ownership (Instr.
4)
|
| Amount |
(A) or (D) |
Price |
| Common Stock |
04/14/2003 |
|
G5
|
12,255 |
D |
$0.00
|
479,696
|
D |
|
| Common Stock |
04/14/2003 |
|
G5
|
12,255 |
A |
$0.00
|
12,255 |
I |
by Trust A
|
| Common Stock |
12/31/2004 |
|
G5
|
206 |
D |
$0.00
|
479,490 |
D |
|
| Common Stock |
12/31/2004 |
|
G5
|
206 |
A |
$0.00
|
12,461 |
I |
by Trust A
|
| Common Stock |
03/22/2005 |
|
G5
|
1,227 |
D |
$0.00
|
478,263 |
D |
|
| Common Stock |
03/22/2005 |
|
G5
|
1,227 |
A |
$0.00
|
13,688 |
I |
by Trust A
|
| Common Stock |
06/30/2008 |
|
G5
|
208 |
D |
$0.00
|
478,055 |
D |
|
| Common Stock |
06/30/2008 |
|
G5
|
208 |
A |
$0.00
|
13,896 |
I |
by Trust A
|
| Common Stock |
09/30/2008 |
|
G5
|
396 |
D |
$0.00
|
477,659 |
D |
|
| Common Stock |
09/30/2008 |
|
G5
|
396 |
A |
$0.00
|
14,292 |
I |
by Trust A
|
| Common Stock |
12/31/2008 |
|
G5
|
226 |
D |
$0.00
|
477,433 |
D |
|
| Common Stock |
12/31/2008 |
|
G5
|
226 |
A |
$0.00
|
14,518 |
I |
by Trust A
|
| Common Stock |
02/09/2009 |
|
G5
|
55,770 |
D |
$0.00
|
421,663 |
D |
|
| Common Stock |
02/09/2009 |
|
G5
|
55,770 |
A |
$0.00
|
70,288 |
I |
by Trust A
|
| Common Stock |
03/31/2009 |
|
G5
|
15,052 |
D |
$0.00
|
406,611 |
D |
|
| Common Stock |
03/31/2009 |
|
G5
|
15,052 |
A |
$0.00
|
85,340 |
I |
by Trust A
|
| Common Stock |
06/30/2009 |
|
G5
|
380 |
D |
$0.00
|
406,231 |
D |
|
| Common Stock |
06/30/2009 |
|
G5
|
380 |
A |
$0.00
|
85,720 |
I |
by Trust A
|
| Common Stock |
09/30/2009 |
|
G5
|
308 |
D |
$0.00
|
405,923 |
D |
|
| Common Stock |
09/30/2009 |
|
G5
|
308 |
A |
$0.00
|
86,028 |
I |
by Trust A
|
| Common Stock |
12/31/2009 |
|
G5
|
138 |
D |
$0.00
|
405,785 |
D |
|
| Common Stock |
12/31/2009 |
|
G5
|
138 |
A |
$0.00
|
86,166 |
I |
by Trust A
|
| Common Stock |
03/16/2010 |
|
G5
|
14,384 |
D |
$0.00
|
391,401 |
D |
|
| Common Stock |
03/16/2010 |
|
G5
|
14,384 |
A |
$0.00
|
100,550 |
I |
by Trust A
|
| Common Stock |
03/31/2010 |
|
G5
|
274 |
D |
$0.00
|
391,127 |
D |
|
| Common Stock |
03/31/2010 |
|
G5
|
274 |
A |
$0.00
|
100,824 |
I |
by Trust A
|
| Common Stock |
04/12/2010 |
|
G5
|
26,492 |
D |
$0.00
|
364,635 |
D |
|
| Common Stock |
04/12/2010 |
|
G5
|
26,492 |
A |
$0.00
|
127,316 |
I |
by Trust A
|
| Common Stock |
06/30/2010 |
|
G5
|
274 |
D |
$0.00
|
364,361 |
D |
|
| Common Stock |
06/30/2010 |
|
G5
|
274 |
A |
$0.00
|
127,590 |
I |
by Trust A
|
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
3)
|
2. Conversion or Exercise Price of Derivative Security
|
3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction 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
(Month/Day/Year) |
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: Direct (D) or Indirect (I) (Instr.
4)
|
11. Nature of Indirect Beneficial Ownership (Instr.
4)
|
| (A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
|
|
| Remarks: |
|
|
/s/ JAMES S. FASSIO President, Chief Development Officer |
03/13/2013 |
|
** 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
4
(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. |
ROSS STORES, INC.
POWER OF ATTORNEY
The undersigned hereby authorizes John G. Call, Group Senior Vice
President; Deon Riley, Senior Vice President, Human Resources;
Ken Jew, Vice President, Corporate Counsel and Assistant
Corporate Secretary; and Monte Young, Senior Director,
Compensation-HRIM of Ross Stores, Inc. (the "Company"), to
execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer or director of the Company,
Form ID Uniform Application for Access Codes and Passwords to
File on EDGAR, Forms 4 and 5, and any amendments thereto, and
cause such form(s) to be filed with the United States Securities
and Exchange Commission pursuant to Section 16(a) of the
Securities Act of 1934, relating to the undersigned's beneficial
ownership of securities in the Company. The undersigned hereby
grants to each such attorney-in-fact full power and authority to
do and perform any and every act and thing whatsoever requisite,
necessary, or proper to be done in the exercise of any of the
rights and powers herein granted, as fully to all intents and
purposes as the undersigned might or could do if personally
present, with full power of substitution or revocation, hereby
ratifying and confirming all that such attorney-in-fact, or such
attorney-in-fact's substitute or substitutes, shall lawfully do
or cause to be done by virtue of this power of attorney and the
rights and powers herein granted. The undersigned acknowledges
that the foregoing attorneys-in-fact, in serving in such capacity
at the request of the undersigned, are not assuming, nor is the
Company assuming, any of the undersigned's responsibilities to
comply with Section 16 of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in full force and effect
until the undersigned is no longer required to file Forms 4 and 5
with respect to the undersigned's holdings of, and transactions
in, securities issued by the Company, unless earlier revoked by
the undersigned in a signed writing delivered to the foregoing
attorneys-in-fact.
In Witness Whereof, the undersigned has caused this Power of
Attorney to be executed as of this 7th day of March, 2013.
/s/ James Fassio
SV\340998.1
