-----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, SQbinx6jzAMhUA0Jd/ZkjdA9ffaM44GmiNuvvZ91DqWNrpAaVSKk/0kjatIwDJ7G NlBFn//ceQSn6Cr26xco6g== 0001179110-04-018472.txt : 20040921 0001179110-04-018472.hdr.sgml : 20040921 20040921191054 ACCESSION NUMBER: 0001179110-04-018472 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20040824 FILED AS OF DATE: 20040921 DATE AS OF CHANGE: 20040921 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: GOSTOMSKI MICHAEL M CENTRAL INDEX KEY: 0000901070 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-16125 FILM NUMBER: 041040115 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: FASTENAL CO CENTRAL INDEX KEY: 0000815556 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-BUILDING MATERIALS, HARDWARE, GARDEN SUPPLY [5200] IRS NUMBER: 410948415 STATE OF INCORPORATION: MN FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2001 THEURER BLVD CITY: WINONA STATE: MN ZIP: 55987 BUSINESS PHONE: 5074545374 4 1 edgar.xml FORM 4 - X0202 4 2004-08-24 0 0000815556 FASTENAL CO FAST 0000901070 GOSTOMSKI MICHAEL M 1666 VALLEY VIEW DRIVE WINONA MN 55987 1 0 0 0 Common Stock 2004-08-24 4 J 0 277403 D 526119 I These shares are held by reporting persons revocable living trust Forward Sales Contract (obligation to buy) 2004-08-24 4 J 0 1 D 2004-08-24 2004-08-24 Common Stock 310000 0 D On October 24, 2002, the reporting person's revocable living trust entered into a previously reported prepaid forward sale contract (the "Contract") with a securities broker which covered a maximum of 310,000 shares and settled on August 24, 2004. Upon signing the Contract the trust trust received an initial cash payment equal to $27.91 per share subject to the Contract in exchange for the trust's obligation to sell and deliver some or all of the shares subject to the Contract on the expiration date of the Contract as follows: upon the expiration of the Contract, one of three delivery scenarios would occur: (i) if the fair market value of the underlying shares on the expiration date was at or below the floor price of $32.65 per share, the trust would deliver all of the underlying shares to the securities broker; (ii) if the fair market value of the underlying shares on the expiration date was above the floor price but below the cap price of $39.18 per share, the trust would deliver a number of underlying shares the value of which, based on the current market price on the expiration date, equals the total number of underlying shares multiplied by the floor price; or (iii) if the fair market value of the underlying shares on the expiration date was at or above the cap price, the trust would deliver a number of underlying shares the value of which, based on the current market price on the expiration date, equals the total number of underlying shares multiplied by the sum of (a) the floor price and (b) the difference between the current market price and the cap price. Alternatively, the trust was permitted, instead of delivering the required number of underlying shares on the expiration date, to make a cash payment to the broker equal to the current fair market value of the number of underlying securities that would have otherwise been delivered. On the settlement date the closing price per share of Fastenal Company common stock was $62.10, which was greater than the cap price. Accordingly, the Contract required the trust to deliver to the securities broker 277,403 shares of Fastenal Company common stock. The trust was not obligated to deliver 32,597 shares of Fastenal Company common stock, and therefore those shares were retained. An additional 262,150 shares are held by the revocable living trust of the reporting person's spouse. The reporting person disclaims beneficial ownership of these shares. /s/Jeffrey R. Sprain as Attorney-in-Fact 2004-09-21 -----END PRIVACY-ENHANCED MESSAGE-----