-----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, DUxWhPf2pozNn1Q/GjgmHN6ZKLcR6F35hdEJzDnQWZtDOPEMuhWP2ZGaAE9G70kq 3eeLH6BSyztF18sONjTqNQ== 0000874214-01-000005.txt : 20010320 0000874214-01-000005.hdr.sgml : 20010320 ACCESSION NUMBER: 0000874214-01-000005 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20010203 FILED AS OF DATE: 20010319 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: TAYLOR ANN STORES CORP CENTRAL INDEX KEY: 0000874214 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-WOMEN'S CLOTHING STORES [5621] IRS NUMBER: 133499319 STATE OF INCORPORATION: DE FISCAL YEAR END: 0130 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 001-10738 FILM NUMBER: 1570971 BUSINESS ADDRESS: STREET 1: 142 WEST 57TH ST CITY: NEW YORK STATE: NY ZIP: 10019 BUSINESS PHONE: 2125413300 COMPANY DATA: COMPANY CONFORMED NAME: DEROSA PATRICIA CENTRAL INDEX KEY: 0001081879 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-WOMEN'S CLOTHING STORES [5621] OTHER STATE OF INCORPORATION: DE FISCAL YEAR END: 0201 FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: C/O ANNTAYLOR STORES CORP STREET 2: 142 WEST 57TH STREET CITY: NEW YORK STATE: NY ZIP: 10019 BUSINESS PHONE: 2125413300 MAIL ADDRESS: STREET 1: C/O ANNTAYLOR STROES CORP STREET 2: 142 WEST 57TH STREET CITY: NEW YORK STATE: NY ZIP: 10019 5 1 0001.htm FORM 5 Form 5 
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                     U.S. SECURITIES AND EXCHANGE COMMISSION
                             Washington, D.C. 20549

                                     FORM 5

               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

[X]  Check box if no longer  subject to Section 16. Form 4 or Form 5 obligations
     may continue. See Instruction 1(b).

[_]  Form 3 Holdings Reported

[_]  Form 4 Transactions Reported

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1.   Name and Address of Reporting Person*

   DeRosa                            Patricia
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   (Last)                            (First)              (Middle)

                   c/o AnnTaylor Stores Corporation
                   142 West 57th Street
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                                    (Street)

   New York                          NY                     10019
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   (City)                            (State)                (Zip)
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2.   Issuer Name and Ticker or Trading Symbol

          AnnTaylor Stores Corporation (ANN)

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3.   IRS Identification Number of Reporting Person, if an Entity (Voluntary)



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4.   Statement for Month/Year

        Fiscal Year Ended February 3, 2001

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



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

     [_]  Director                             [_]  10% Owner
     [_]  Officer (give title below)           [X]  Other (specify below)
                                                    Former Director and
                                                      Officer

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7.   Individual or Joint/Group Filing
     (Check applicable line)

     [X]  Form filed by one Reporting Person
     [_]  Form filed by more than one Reporting Person
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           Table I -- Non-Derivative Securities Acquired, Disposed of,
                             or Beneficially Owned
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                                                                                                 5.             6.
                                                                 4.                              Amount of      Owner-
                                                                 Securities Acquired (A) or      Securities     ship
                                                                 Disposed of (D)                 Beneficially   Form:     7.
                                                                 (Instr. 3, 4 and 5)             Owned at End   Direct    Nature of
                                      2.            3.           -----------------------------   of Issuer's    (D) or    Indirect
1.                                    Transaction   Transaction                  (A)             Fiscal Year    Indirect  Beneficial
Title of Security                     Date          Code             Amount      or     Price    (Instr. 3      (I)       Ownership
(Instr. 3)                            (mm/dd/yy)    (Instr. 8)                   (D)             and 4)         (Instr.4) (Instr. 4)
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Common Stock (restricted shares)      2/16/00        A               50,000       A     ---      10,000          D
                                                                                                  See Note 1


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Note 1:  The 50,000 restricted shares reported here were canceled upon reporting person's separation from the Company on 1/15/01.

*    If the form is filed by more than one  Reporting  Person,  see  Instruction
     4(b)(v).

Reminder:  Report on a separate line for each class of  securities  beneficially
owned directly or indirectly.


                                                                          (Over)
(Form 5-07/98)
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FORM 5 (continued)

Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
         (e.g., puts, calls, warrants, options, convertible securities)

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                                                                                                         9.          10.
                                                                                                         Number      Owner-
                                                                                                         of          ship
                2.                                                                                       Deriv-      of
                Conver-                    5.                              7.                            ative       Deriv-   11.
                sion                       Number of                       Title and Amount              Secur-      ative    Nature
                or                         Derivative    6.                of Underlying        8.       ities       Secur-   of
                Exer-                      Securities    Date              Securities           Price    Bene-       ity:     In-
                cise     3.                Acquired (A)  Exercisable and   (Instr. 3 and 4)     of       ficially    Direct   direct
                Price    Trans-   4.       or Disposed   Expiration Date   -------------------  Deriv-   Owned       (D) or   Bene-
1.              of       action   Trans-   of (D)        (Month/Day/Year)               Amount  ative    at End      In-      ficial
Title of        Deriv-   Date     action   (Instr. 3,    -------------------            or      Secur-   of          direct   Owner-
Derivative      ative    (Month/  Code     4 and 5)      Date        Expira-            Number  ity      Year        (I)      ship
Security        Secur-   Day/     (Instr.  ------------  Exer-       tion               of      (Instr.  (Instr.     (Instr.  (Instr
(Instr. 3)      ity      Year)    8)        (A)   (D)    cisable     Date     Title     Shares  5)       4)          4)       4)
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Employee                                                  See         See      Common
  Stock Options $16.875   2/16/00  A        100,000 ---   Note 2      Note 2   Stock     100,000 $16.875  0           D

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Employee                                                  See         See      Common                     97,250
  Stock Options $23.9375  3/10/00  A         40,000 ---   Note 3      Note 3   Stock      40,000 $23.9375 See         D
                                                                                                          Note 4

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================================================================================================================================

Explanation of Responses:

Note 3:  Become exercisable 25% per year, on each anniversary of grant.  Unvested and vested unexercised options will be canceled
         4/15/03, subject to earlier expiration upon occurence of specified events.

Note 4:  Includes other stock options having different terms, previously reported.  All such options will expire 4/15/03, or
         earlier upon occurence of specified events.

     /s/ Patricia DeRosa                                      3/15/2001
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      **Signature of Reporting Person                             Date

**   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 provided is insufficient, see Instruction 6 for procedure.
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