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OMB APPROVAL
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OMB Number: 3235-0362
Expires: December 31, 2001
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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
[_] Check this 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*
Goldberg Mark J.
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(Last) (First) (Middle)
c/o Fab Industries, Inc., 200 Madison Avenue
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(Street)
New York NY 10016
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Fab Industries, Inc. ("FIT")
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Year
01/02
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
Vice President of Operations
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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
2. 3. Disposed of (D) Beneficially Form: 7.
Transaction Transaction (Instr. 3, 4 and 5) Owned at End Direct Nature of
Date Code ------------------------------- of Issuer's (D) or Indirect
1. (Month/ (Instr. 8) (A) Fiscal Year Indirect Beneficial
Title of Security Day/ ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) Year) Code (D) and 4) (Instr.4) (Instr. 4)
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Common Stock, par value
$0.20 per share 8/1/2001 A 133 A (1) 994 I By ESOP
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* If the form is filed by more than one reporting person, see
Instruction 4(b)(v).
POTENTIAL PERSONS WHO ARE TO 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.
(Over)
SEC 2270 (3/99)
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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10.
9. Owner-
Number ship
of Form
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 Stock
Option (right to
buy) $13.00 10/27/99 A 7,000 (2) 10/27/09 Common Stock 7,000 7,000 D
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Explanation of Responses:
(1) Represents shares allocated under the Fab Industries, Inc. Employees Stock
Ownership Plan.
(2) The shares become exercisable in five equal annual installments on October
27, 2000.
/s/ Mark J. Goldberg January 8, 2002
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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.
Potential persons who are to 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.
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