SEC 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
|Estimated average burden|
|hours per response:
1. Name and Address of Reporting Person*
2. Date of Event Requiring Statement
3. Issuer Name and Ticker or Trading Symbol
ROSS STORES, INC.
[ ROST ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
||Officer (give title below)
||Other (specify below)
EVP, Chief Financial Officer
5. If Amendment, Date of Original Filed
6. Individual or Joint/Group Filing (Check Applicable Line)
||Form filed by One Reporting Person
||Form filed by More than One Reporting Person
|Table I - Non-Derivative Securities Beneficially Owned|
|1. Title of Security (Instr.
Amount of Securities Beneficially Owned (Instr.
||3. Ownership Form: Direct (D) or Indirect (I) (Instr.
||4. Nature of Indirect Beneficial Ownership (Instr.
Table II - Derivative Securities Beneficially Owned|
(e.g., puts, calls, warrants, options, convertible securities)
|1. Title of Derivative Security (Instr.
||2. Date Exercisable and Expiration Date
||3. Title and Amount of Securities Underlying Derivative Security (Instr.
||4. Conversion or Exercise Price of Derivative Security
||5. Ownership Form: Direct (D) or Indirect (I) (Instr.
||6. Nature of Indirect Beneficial Ownership (Instr.
||Amount or Number of Shares
|Explanation of Responses:|
||/s/ Ken Jew for Adam Orvos
||** Signature of Reporting Person
|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,
|** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
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,
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 designates and appoints as
his/her attorney-in-fact and authorizes each of: Ken
Jew, Group Senior Vice President, General Counsel and
Corporate Secretary; Kevin Reimann, Group Senior Vice
President, Human Resources; Brian Frost, Senior Vice
President, Human Resources and Marcia Casey, Vice
President, Human Resources 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 3, 4, and 5, and any amendments thereto,
and to 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
In Witness Whereof, the undersigned has caused this
Power of Attorney to be executed as of this 22nd day
of September 2021.
/s/ Adam Orvos