- Annual Statement of Changes in Beneficial Ownership (5)
21 January 2010 - 7:01AM
Edgar (US Regulatory)
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FORM 5
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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Form 3 Holdings Reported
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Expires:
February 28, 2011
Estimated average burden
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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
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1. Name and Address of Reporting Person
*
LORBERBAUM JEFFREY S
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2. Issuer Name
and
Ticker or Trading Symbol
MOHAWK INDUSTRIES INC [MHK]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chairman and CEO
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(Last)
(First)
(Middle)
160 SOUTH INDUSTRIAL BLVD., P.O. BOX 12069
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2009
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(Street)
CALHOUN, GA 30703
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. 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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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Amount
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(A) or (D)
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Price
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Common Stock
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9/8/2009
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S
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100000
(1)
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D
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$49.04
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2635604
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I
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Fam.Ltd.Partnership
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Common Stock
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9/9/2009
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S
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150000
(1)
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D
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$49.85
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2485604
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I
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Fam.Ltd.Partnership
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Common Stock
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9/10/2009
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S
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50000
(1)
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D
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$49.71
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2435604
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I
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Fam.Ltd.Partnership
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Common Stock
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9/11/2009
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S
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56282
(1)
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D
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$49.38
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2379322
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I
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Fam.Ltd.Partnership
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Common Stock
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217196
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D
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Common Stock
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8423438
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I
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Aladdin Partners, LP
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Common Stock
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194
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I
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by Managed Account
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(
1)
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The general partner of JMS Group Limited Partnership ("JMS") is SJL Management company, LLC ("SJL"). The reporting person, Ms. Suzanne L. Helen and Mr. Mark Lorberbaum are equal members of SJL, and each of them reports indirect ownership of 100% of the issuer shares held by JMS, but disclaims beneficial ownership of these shares except to the extent of his or her individual pecuniary interest in such shares. The number of shares reported on this Form 5 as indirectly owned through JMS excludes 356,282 shares previously reported as indirectly owned by the reporting person which were distributed to Mark Lorberbaum on a pro rata basis in connection with a redemption of his limited partnership interest in JMS.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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LORBERBAUM JEFFREY S
160 SOUTH INDUSTRIAL BLVD.
P.O. BOX 12069
CALHOUN, GA 30703
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X
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Chairman and CEO
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Signatures
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JEFFREY S. LORBERBAUM
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1/20/2010
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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