-----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, O5BNtYuQNacwB3K+NX1YLvCinQv4C7Qjvee4JVgfbJMzN/T4+C1mzT4zkzW2c5hN yJ4gfYyGbLZoHvdvCNKvEQ== 0001179110-10-016669.txt : 20101129 0001179110-10-016669.hdr.sgml : 20101129 20101129191543 ACCESSION NUMBER: 0001179110-10-016669 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20101124 FILED AS OF DATE: 20101129 DATE AS OF CHANGE: 20101129 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: 101220207 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 - X0303 4 2010-11-24 0 0000815556 FASTENAL CO FAST 0000901070 GOSTOMSKI MICHAEL M 1666 VALLEY VIEW DRIVE WINONA MN 55987 1 0 0 0 Common Stock 2010-11-24 5 G 0 E 47978 0 A 446882 I By trust Common Stock 2010-11-24 4 J 0 172022 53.93 A 618904 I By trust Common Stock 2010-11-24 5 G 0 E 47978 0 D 29300 I By spouse's trust Common Stock 2010-11-24 4 J 0 172022 53.93 D 0 I By Spouse's GRAT Common Stock 2223 D Common Stock 2223 I By spouse Common Stock 12000 I By trust Forward sale contract (obligation to sell) 2010-11-24 4 J 1 220000 0 A 2011-11-23 2011-11-23 Common Stock 220000 220000 I By trust Shares held in reporting person's revocable living trust for which the reporting person has voting and investment power; the revocable living trust is also party to forward sale contract described in Table II. Reporting person's revocable living trust received 172,022 Fastenal common shares from his spouse's grantor retained annuity trust in exchange for $9,277,146. Shares held in reporting person's spouse's revocable living trust for which the spouse has voting and investment power. Shares held in a charitable remainder unit trust for which the reporting person and his spouse share voting and investment power. On November 24, 2010, the reporting person entered into a prepaid variable forward contract with an unaffiliated third-party buyer. The contract obligates the reporting person to deliver to the buyer up to 220,000 shares of Fastenal Company common stock (or, at the reporting person's election, an equivalent amount of cash based on the market price of Fastenal common stock at that time) on the maturity date of the contract (November 23, 2011). In exchange for assuming this obligation, the reporting person will receive a cash payment of $9,438,000. The reporting person pledged 220,000 Fastenal common shares (the "Pledged Shares") to secure his obligations under the contract, and retains dividend and voting rights in the Pledged Shares during the term of the pledge. (continued from footnote 5) The number of Fastenal common shares to be delivered to the buyer on the maturity date is to be determined as follows: (i) if the closing price of Fastenal common stock on the maturity date (the "Settlement Price") is less than or equal to $48.54 (the "Floor Price"), the reporting person will deliver to the buyer all of the Pledged Shares; (ii) if the Settlement Price is between the Floor Price and $70.11 (the "Cap Price"), the reporting person will deliver to the buyer a number of Fastenal common shares equal to 220,000 times the Floor Price divided by the Settlement Price; and (iii) if the Settlement Price is greater than the Cap Price, the reporting person will deliver to the buyer a number of Fastenal common shares equal to 220,000 times a fraction whose numerator is the Floor Price plus the difference between the Settlement Price and the Cap Price, and whose denominator is the Settlement Price. /s/ John Milek, Attorney-in-Fact 2010-11-29 -----END PRIVACY-ENHANCED MESSAGE-----