0000899243-21-006780.txt : 20210216
0000899243-21-006780.hdr.sgml : 20210216
20210216204618
ACCESSION NUMBER: 0000899243-21-006780
CONFORMED SUBMISSION TYPE: 5
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210102
FILED AS OF DATE: 20210216
DATE AS OF CHANGE: 20210216
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: MATTHEWS NORMAN S
CENTRAL INDEX KEY: 0001178445
FILING VALUES:
FORM TYPE: 5
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38950
FILM NUMBER: 21642182
MAIL ADDRESS:
STREET 1: 650 MADISON AVENUE, 23RD FLOOR
CITY: NEW YORK
STATE: NY
ZIP: 10022
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Grocery Outlet Holding Corp.
CENTRAL INDEX KEY: 0001771515
STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-GROCERY STORES [5411]
IRS NUMBER: 471874201
STATE OF INCORPORATION: DE
FISCAL YEAR END: 0102
BUSINESS ADDRESS:
STREET 1: 5650 HOLLIS STREET
CITY: EMERYVILLE
STATE: CA
ZIP: 94608
BUSINESS PHONE: (510) 845-1999
MAIL ADDRESS:
STREET 1: 5650 HOLLIS STREET
CITY: EMERYVILLE
STATE: CA
ZIP: 94608
5
1
doc5.xml
FORM 5 SUBMISSION
X0306
5
2021-01-02
0
0
0
0001771515
Grocery Outlet Holding Corp.
GO
0001178445
MATTHEWS NORMAN S
C/O GROCERY OUTLET HOLDING CORP.,
5650 HOLLIS STREET
EMERYVILLE
CA
94608
1
0
0
0
Common Stock
2020-12-01
5
G
0
123849
0.00
D
25897
D
Common Stock
2020-12-01
5
G
0
123849
0.00
A
123849
I
By Matthews Family Trust
Represents a gift made by Mr. Matthews to the Matthews Family 2020 Trust dtd 11/24/2020.
These totals also reflect shares of Common Stock received by Mr. Matthews in connection with a pro rata in-kind distribution made by H&F Globe Investor LP to its partners in a distribution exempt from Section 16 of the Securities Exchange Act of 1934 by virtue of Rule 16a-9 thereunder
Reflects shares directly held by the Matthews Family 2020 Trust dtd 11/24/2020 of which Mr. Matthews is a co-trustee.
/s/ Pamela B. Burke, as Attorney-in-Fact
2021-02-16