Form 5 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION 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 | OMB APPROVAL | |
OMB Number: 3235-0362 | |||
Expires: January 31, 2005 | |||
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[_] [_] | 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 | Estimated average burden |
1. Name and Address of Reporting Person* Shaffer Donald S. | 2. Issuer Name and Ticker or Trading Symbol Dollar General Corporation (DG) | 6. Relationship of Reporting Person(s) to Issuer
title below) below) Acting Chief Executive Officer, President and Chief Operating Officer | |
(Last) (First) (Middle) 100 Mission Ridge | 3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary) | 4. Statement for Month/Year January 31, 2003 | |
(Street) Goodlettsville TN 37072 | 5. If Amendment, Date of Original (Month/Year) | 7. Individual or Joint/Group Filing | |
(City) (State) (Zip) | Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
1. Title of Security | 2. Trans- | 2A. | 3. Transaction | 4. Securities Acquired (A) or Disposed of (D) | 5. Amount of Securities Beneficially Owned at the end of Issuer's Fiscal Year (Instr. 3 and 4) | 6. Owner- | 7. Nature of Indirect Beneficial Ownership | ||
Amount | (A) | Price | |||||||
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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 Number. | (Over) |
FORM 5 (continued) | Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned |
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1.Title of Derivative Security | 2. Conversion or | 3. Transaction | 3A. Deemed | 4. Transaction Code | 5. Number of Derivative | 6. Date Exercisable | 7. Title and Amount of Underlying Securities | 8. Price of | 9. Number of Derivative Securities Beneficially Owned at End of Year (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date | Expiration | Title | Amount or | ||||||||
Employee Stock Option (Right to Buy) | $16.14 | 08/12/02 | A | 137,600 | (1) | 08/12/12 | Common Stock | 137,600 | 137,600 | D | |||||
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Explanation of Responses: The option vests in four equal annual installments beginning on August 12, 2003. |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | /s/ Donald S. Shaffer **Signature of Reporting Person | 3/9/03 Date |
Note: | File three copies of this Form, one of which must be manually signed. If space provided is insufficient, see Instruction 6 for procedure. |
Potential persons who are to respond to the collection of information contained in this form are not | Page 2 |