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