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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES 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(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 2270 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | |||||||||
Option - right to buy (4) | $ 25.26 | Â | Â | Â | Â | Â | 06/23/2012 | 06/23/2019 | Common Stock | Â | 15,300 | Â | ||
Option - right to buy (5) | $ 44.39 | Â | Â | Â | Â | Â | 06/23/2014 | 06/23/2021 | Common Stock | Â | 20,000 | Â | ||
Restricted stock units (6) | Â | Â | Â | Â | Â | Â | Â (6) | Â (6) | Common Stock | Â | 3,250 | Â | ||
Restricted stock units (8) | Â | Â | Â | Â | Â | Â | Â (8) | Â (8) | Common Stock | Â | 3,250 | Â | ||
Restricted stock units (9) | Â | Â | Â | Â | Â | Â | Â (9) | Â (9) | Common Stock | Â | 3,250 | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Walljasper William J ONE CONVENIENCE BLVD. PO BOX 3001 ANKENY, IA 50021 |
 |  |  Senior VP and CFO |  |
Scott Faber, under Power of Attorney dated March 3, 2017 | 07/18/2017 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | The number of shares reported reflects a bona fide gift of shares to a charitable organization on the transaction date that has not been previously reported by Mr. Walljasper. The omitted shares also were included in the Table I, Column 5 beneficial ownership reported in the intervening Forms 4 and 4/A filed by Mr. Walljasper between the applicable transaction date and this Form 5. |
(2) | Reflects the number of shares directly owned by Mr. Walljasper as of the end of Casey's fiscal year, April 30, 2017, taking into account the amendment reported on Form 4/A being filed with this Form 5. |
(3) | Allocated to Mr. Walljasper's 401k plan account as of the end of Casey's fiscal year, April 30, 2017. Does not include any shares allocated by the plan trustee after that date. |
(4) | Pursuant to terms and conditions of 2000 Stock Option Plan (or predecessor plan). |
(5) | Pursuant to terms and conditions of 2009 Stock Incentive Plan. |
(6) | Pursuant to terms and conditions of 2009 Stock Incentive Plan. As reported in the intervening Form 4 on June 6, 2017, this award vested in full on June 6, 2017; however, the holding (and the other holdings in Table II) reflects Mr. Walljasper's ownership of derivative securities as of the end of Casey's fiscal year, April 30, 2017. |
(7) | Each restricted stock unit represents the right to receive, following vesting, one share of Common Stock. |
(8) | Pursuant to terms and conditions of 2009 Stock Incentive Plan. This award will vest in full on June 5, 2018. |
(9) | Pursuant to terms and conditions of 2009 Stock Incentive Plan. This award will vest in full on June 2, 2019. |