-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, BVmznerxSMM70bXpv5I3AEwgph3QkvdELwLrQSgmW9mtoLR9TsDrJPbZSD0fx4un ROlzOI6SINSpUCEP99GFCg== 0001181431-03-004283.txt : 20030314 0001181431-03-004283.hdr.sgml : 20030314 20030314140854 ACCESSION NUMBER: 0001181431-03-004283 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030201 FILED AS OF DATE: 20030314 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: WILLARDSON THOMAS D CENTRAL INDEX KEY: 0001206495 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: C/O COST PLUS INC STREET 2: 200 FOURTH STREET CITY: OAKLAND STATE: CA ZIP: 94607 BUSINESS PHONE: 5108937300 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: COST PLUS INC/CA/ CENTRAL INDEX KEY: 0000798955 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-HOME FURNITURE, FURNISHINGS & EQUIPMENT STORES [5700] IRS NUMBER: 941067973 STATE OF INCORPORATION: CA FISCAL YEAR END: 0130 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-14970 FILM NUMBER: 03603825 BUSINESS ADDRESS: STREET 1: 201 CLAY ST STREET 2: P O BOX 23350 CITY: OAKLAND STATE: CA ZIP: 94607 BUSINESS PHONE: 4158937300 MAIL ADDRESS: STREET 1: 201 CLAY ST STREET 2: P O BOX 23350 CITY: OAKLAND STATE: CA ZIP: 94623 5 1 rrd6279.htm FORM 5 SEC Form 5
FORM 5

[  ] 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

[X] Form 4 Transactions Reported
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, Section 17(a) of the Public Utility
Holding Company Act of 1935 or Section 30(f) of the Investment Company Act of 1940
OMB APPROVAL



OMB Number: 3235-0362
Expires: January 31, 2005
Estimated average burden
hours per response. . . . . 1.0
1. Name and Address of Reporting Person*
Willardson, Thomas

(Last)                      (First)                      (Middle)
200 4th Street

(Street)
Oakland,    CA   94607

(City)                      (State)                      (Zip)

2. Issuer Name
and Ticker or Trading Symbol

Cost Plus, Inc.
CPWM

3. I.R.S. Identification
    Number of Reporting
    Person, if an entity
    (voluntary)
4. Statement for
    Month/Year

02/01/2003


5. If Amendment,
    Date of Original
    (Month/Year)

6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X Director      10% Owner
   Officer (give title below)        Other (specify below)

Description          

7. 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)





        Amount      /         A/D         /         Price          
5. Amount of
    Securities
    Beneficially
    Owned at end of
    Issuer's Fiscal Year

    (Instr. 3 and 4)
6. Owner-
    ship
    Form:
    Direct (D)
    or
    Indirect (I)

    (Instr. 4)
7. Nature of
     Indirect
     Beneficial
     Ownership

    (Instr. 4)

 
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. Conver-
    sion or
    Exercise
    Price of
    Deri-
    vative
    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)





  A     or     D  
6. Date Exercisable(DE) and
    Expiration Date(ED)
    (Month/Day/Year)






  DE     /     ED  
7. Title and Amount of
    Underlying Securities
    (Instr. 3 and 4)






Title     /         Amount or Number of Shares
8. Price
    of
    Derivative
    Security
    (Instr.5)
9. Number of
    Derivative
    Securities
    Beneficially
    Owned
    at End of Year
    Reported
    Transaction(s)
    (Instr.4)
10. Owner-
ship
Form of
Deriv-
ative
Securities:
Direct (D)
or
Indirect (I)

(Instr.4)
11. Nature of
      Indirect
      Beneficial
      Ownership
      (Instr.4)
Stock Option (right to buy) $21.80 07/22/2002
A4
6000 A
(1) / 7/22/2012
Common Stock / 6000
$
6000
D
Explanation of Responses:
 
(1) Option shall become vested and exercisable as to one-fourth of the aggregate number of shares covered by the Option each year on the anniversary of the grant date, which date is 7/22/02.
By: Date:
/s/ Thomas D. Willardson 03/14/2003
Director
** Signature of Reporting Person
SEC 2270 (09-02)


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.
Potential persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB Number.
-----END PRIVACY-ENHANCED MESSAGE-----