FORM 5 |
UNITED STATES SECURITIES
AND EXCHANGE COMMISSION |
OMB APPROVAL |
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b). |
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(h) of the Investment Company Act of 1940 |
OMB Number:
3235-0362 Filed By |
1. Name and Address of Reporting Person* THOMPSON CHET L |
2. Issuer Name and
Ticker or Trading Symbol |
6. Relationship of
Reporting Person(s)
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(Last) (First) (Middle) 5 PLEASANT RIDGE DR |
3. I.R.S. Identification
Number 314-36-6976 |
4. Statement for Month/Year 12/2002 |
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(Street) WASHINGTON, IN 47501 |
5. If Amendment, Date of Original (Month/Year) |
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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(City) (State) (Zip) |
Table I Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
1. Title of Security |
2. Trans- |
2A. Deemed |
3. Trans- |
4. Securities Acquired
(A) or Disposed of (D) |
5. Amount of |
6. Owner- |
7. Nature of Indirect
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Amount |
(A) |
Price |
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COMMON STOCK |
6/3/02 |
|
A |
876 |
A |
$16.45 |
8042.7841(1) |
D |
|
COMMON STOCK |
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|
|
|
|
|
3342.0001(1) |
I |
BY SPOUSE |
COMMON STOCK |
|
|
|
|
|
|
7372.5949(1) |
D |
JT WITH SPOUSE |
COMMON STOCK |
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|
|
|
|
|
7182(2) |
I |
IN SPOUSE'S IRA |
Reminder:
Report on a separate line for each class of securities beneficially owned
directly or indirectly. * If the form is filed by more than one reporting person, see Instruction 4(b)(v). 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 |
FORM 5 (continued) |
Table II -
Derivative Securities Acquired, Disposed of, or Beneficially Owned |
1. Title of Derivative
Security |
2. Conver- |
3. Trans- |
3A. Deemed Execution Date, if any (Month/ Day/ Year) |
4. Trans- |
5. Number of Derivative
Securities Acquired (A) or Disposed of (D) |
6. Date Exercisable |
7. Title and Amount
of Underlying Securities |
8. Price of Derivative
Security |
9. Number of |
10. Owner- |
11. Nature of Indirect
Beneficial Ownership |
|||
(A) |
(D) |
Date Exer-cisable |
Expira- |
Title |
Amount or Number
of |
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NON-EMPLOYEE DIRECTOR STOCK OPTION (RIGHT TO BUY) | $16.45 |
6/3/02 |
|
A |
1000(3) |
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6/3/02 |
6/3/012 |
COMMON STOCK |
1000 |
|
1050(4) |
D |
|
Explanation of Responses: (1) Reflects additional shares acquired pursuant to a five percent stock dividend to shareholders of record November 30, 2002 and payable on December 15, 2002 as well as shares allocated pursuant to a dividend reinvestment program. |
By:
/s/ Mark A Schroeder POA for Chet L Thompson **Signature of Reporting Person |
1/28/03 Date |
**Intentional misstatements
or omissions of facts constitute Federal Criminal Violations. Note: File three
copies of this Form, one of which must be manually signed. 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.
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