FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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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). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
EXCHANGE NATIONAL BANCSHARES INC [ EXJF ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 12/11/2003 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) 12/19/2003 |
6. Individual or Joint/Group Filing (Check Applicable Line)
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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) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Common Stock | 12/11/2003 | G | 1,217 | A | $0 | 29,045.634 | D(1) | |||
Common Stock | 12/11/2003 | G | 1,217 | D | $0 | 12,835.387 | I | See Note(2) | ||
Common Stock | 759.402 | I | See Note(3) | |||||||
Common Stock | 17,308.25 | I | See Note(4) | |||||||
Common Stock | 0 | I | See Note(5) | |||||||
Common Stock | 0 | I | See Note(6) |
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 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 Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
1. Owned by David R. Goller Trust, David R. Goller Trustee. The shares reported include 9,070 shares acquired from the 7/15/03 3 for 2 stock split and 618.634 shares acquired from 2003 dividend reinvestments. |
2. Owned by Goller, Gardner & Feather PC Profit Sharing Trust, David Goller Trustee. The shares reported include 4,580 shares acquired from the 7/15/03 3 for 2 stock spllit and 312.387 shares acquired from 2003 dividend reinvestments. |
3. Owned by Marie E. Goller Trust 12/2/89, David R. Goller Trustee. The shares reported include 250 shares acquired from the 7/15/03 3 for 2 stock split and 9.402 shares acquired from 2003 dividend reinvestments. |
4. Owned by Marie E. Goller Trust 5/23/83, David R. Goller Trustee. The shares reported include 5,698 shares acquired from the 7/15/03 3 for 2 stock split and 214.25 shares acquired from 2003 dividend reinvestments. |
5. The reporting person no longer has a reportable beneficial interest in the 1,725 shares of common stock included in his prior ownership report and identified as being owned by his now deceased wife. |
6. The reporting person no longer has a reputable beneficial interest in the 60 shares of common stock included in his prior ownership report and identified as being owned by his step-daughter and now deceased wife. |
/s/ Kathleen L. Bruegenhemke, Attorney in Fact | 12/19/2003 | |
** Signature of Reporting Person | Date | |
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). | ||
** 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 is insufficient, see Instruction 6 for procedure. | ||
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. |