-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, Ly2mXBt23mA6cQoRjSOOsqSTOOyMgUJfoeBc/SaEwdE6bRHWiT+80cEFPiIB+M/e 1isky/TgAP8y3+4hUYO7XQ== 0000895813-02-000205.txt : 20021101 0000895813-02-000205.hdr.sgml : 20021101 20021101122722 ACCESSION NUMBER: 0000895813-02-000205 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021101 FILED AS OF DATE: 20021101 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: FIRST MID ILLINOIS BANCSHARES INC CENTRAL INDEX KEY: 0000700565 STANDARD INDUSTRIAL CLASSIFICATION: STATE COMMERCIAL BANKS [6022] IRS NUMBER: 371103704 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-13368 FILM NUMBER: 02806219 BUSINESS ADDRESS: STREET 1: 1515 CHARLESTON AVE STREET 2: PO BOX 499 CITY: MATTOON STATE: IL ZIP: 61938 BUSINESS PHONE: 2172347454 MAIL ADDRESS: STREET 1: 1515 CHARLESTON AVENUE STREET 2: PO BOX 499 CITY: MATTOON STATE: IL ZIP: 61938 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: GRISSOM STEVEN L CENTRAL INDEX KEY: 0001073304 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: C/O CONSOLIDATED COMMUNICATIONS INC STREET 2: 121 S 17TH ST CITY: MATTOON STATE: IL ZIP: 61938 BUSINESS PHONE: 2172354410 MAIL ADDRESS: STREET 1: CONSOLIDATED COMMUNICATIONS INC STREET 2: 121 S 17TH ST CITY: MATTOON STATE: IL ZIP: 61938 4 1 x1101slg4.txt STEVEN L. GIRSSOM UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 FORM 4 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 Instructions 1(b). 1. Name and Address of Reporting Person: Grissom, Steven L. 21 S. Country Club Road Mattoon, IL 61938 U.S.A. 2. Issuer Name and Ticker or Trading Symbol: First Mid-Illinois Bancshares, Inc. (FMBH.OB) 3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary): 4. Statement for Month/Day/Year: November 1, 2002 5. If Amendment, Date of Original (Month/Day/Year): 6. Relationship of Reporting Person(s) to Issuer (Check all applicable): (x) Director ( ) 10% Owner ( ) Officer (give title below) ( ) Other (specify below): 7. Individual or Joint/Group Filing (Check Applicable Line): (x) Form filed by One Reporting Person ( ) Form filed by More than One Reporting Person Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
5. Amount of 6. 2A. Securities Ownership Deemed Beneficially Form: 7. 2. Trans- Execution 3. Owned Direct Nature of action Date, if Trans- 4. Securities Following (D) or Indirect 1. Title of Date any action Acquired (A) or Reported Indirect Beneficial Security (Month/ (Month/ Code Disposed of (D) Transaction(s) (I) Ownership (Instr. 3) Day/Year) Day/Year (Instr. 8) (Instr. 3, 4 and 5) (Instr. 3 and 4) (Instr. 4) (Instr.4) ----------- --------- -------- ---------- ------------------- ---------------- ---------- ---------- Code V Amount (A)or(D) Price ---- - ------ -------- ----- Common Stock 16,848.860 D Common Stock 11/1/02 J(1) 82,500 A $27.50 82,500 I (2) Common Stock 11/1/02 J(1) 82,500 A $27.50 82,500 I (3)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
9. Number of 5. deriv- Number ative 10. of Secur- Owner- 2. Deriv- ities ship Conver- ative Benefi- Form of 11. sion 3A. Secur- cially Deriv- Nature 1. or Deemed ities 8. Owned ative of Title Exer- Execu- Acquired Price Follow- Secur- In- of cise 3. tion (A) or 6. 7. of ing ities: direct Deriv- Price Trans- Date, 4. Dis- Date Title and Deriv- Re- Direct Bene- ative of action if Trans- posed Exercisable Amount of ative ported (D) or ficial Secur- Deriv- Date any, action of (D) and Underlying Secur- Transac- Indirect Owner- ity ative (Month/ (Month/ Code (Instr. Expiration Securities ity tion(s) (I) ship (Instr. Secur- Day/ Day/ (Instr. 3, 4 Date (Month/ (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) Year) 8) and 5) Day/Year) (3 and 4) 5) 4) 4) 4) ------- ------ ------ ------- ------- -------- ----------- ---------- ------- ------- -------- ------- Amount or Exer- Expir- Number cis- ation of Code V (A) (D) able Date Title Shares ---- - --- --- ---- ----- ----- ------ Stock Option 1,750 D Reminder: Report on a separate line for each class of securities beneficially owned directly of 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. ________________________________________ ____________________ **Signature of Reporting Person Date Attorney-in-Fact Explanation of Responses: (1) The following shares were transferred by Mr. Richard A. Lumpkin: (a) 82,500 shares to the Richard Anthony Lumpkin 1990 Personal Income Trust for the Benefit of Benjamin Iverson Lumpkin dated 4/20/90, under which Mr. Grissom serves as co-trustee; and (b) 82,500 shares to the Richard Anthony Lumpkin 1990 Personal Income Trust for the Benefit of Elizabeth Arabella Lumpkin dated 4/20/90, under which Mr. Grissom serves as co-trustee. (2) By Mr. Grissom as co-trustee of the Richard Anthony Lumpkin 1990 Personal Income Trust for the Benefit of Benjamin Iverson Lumpkin dated 4/20/90. Mr. Grissom disclaims beneficial ownership of these shares. (3) By Mr. Grissom as co-trustee of the Richard Anthony Lumpkin 1990 Personal Income Trust for the Benefit of Elizabeth Arabella Lumpkin dated 4/20/90. Mr. Grissom disclaims beneficial ownership of these shares.
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