-----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, ACgFx+hicQLQyeUWJWHtipG7LMacRO9Gyq9bimoR84h5SL6bXcPFs0BeTQWdgq3t Zbw4EqAjkGQs0EKce75ahQ== 0001104659-03-001723.txt : 20030212 0001104659-03-001723.hdr.sgml : 20030212 20030212140609 ACCESSION NUMBER: 0001104659-03-001723 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030212 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: WOLLMAN HARVEY L CENTRAL INDEX KEY: 0001185783 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: RURAL RT. 1, BOX 75 CITY: FRANKFORT STATE: SD ZIP: 57440 BUSINESS PHONE: 7012985625 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: COMMUNITY FIRST BANKSHARES INC CENTRAL INDEX KEY: 0000857593 STANDARD INDUSTRIAL CLASSIFICATION: STATE COMMERCIAL BANKS [6022] IRS NUMBER: 460391436 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-19368 FILM NUMBER: 03553706 BUSINESS ADDRESS: STREET 1: 520 MAIN AVENUE CITY: FARGO STATE: ND ZIP: 58124-0001 BUSINESS PHONE: 7012985600 MAIL ADDRESS: STREET 1: 520 MAIN AVENUE CITY: FARGO STATE: ND ZIP: 58124-0001 5 1 j7375_5.htm 5

FORM 5

 

      Check 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

UNITED STATES SECURITIES AND EXCHANGE COMMISSION

Washington, D.C.  20549


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

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 1. Name and Address of Reporting Person

Wollman Harvey L

(Last)            (First)              (Middle)



40004, 184th Street

(Street)



Frankfort, SD 57440

(City)       (State)          (Zip)

 2. Issuer Name and Ticker
    or Trading Symbol

Community First Bankshares, Inc.
CFBX


 3. I.R.S. Identification
    Number of Reporting
    Person, if an entity
    (voluntary)




 4. Statement for Month/Year



December

2002



 5. If Amendment, Date of
    Original (Month/Year)




 6. Relationship of Reporting Person(s) to Issuer
    (Check all applicable)

 X  Director

      Officer
(give title below)

     10% Owner

     Other
(specify below)


                                  


 7. Individual or Joint/Group Reporting
    (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

 

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 at the
    end of Issuer's     Fiscal Year
    (Instr. 3 and 4)

6. Owner-
    ship
    Form:
    Direct(D)
    or
    Indirect (I)
    (Instr. 4)

7.  Nature of
     Indirect
     Beneficial
     Ownership
     (Instr. 4)

Amount

(A) or (D)

Price

Common Stock

 

 

 

 

 

 

23,101

D

 

 

 

 

 

 

 

 

4,310 (a)

1

Def. Comp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)  Includes 1,360 shares purchased, not previously reported.

 

* If the form is filed by more than one reporting person, see instruction 4(b)(v).


 

Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)

 

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 Underlying Securities
(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 of Derivative Securities: 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

Option*

$24.6875

 

 

 

 

 

 

4/28/98

4/28/03

Common Stock

4,000

 

4,000

D

 

Option*

$20.375

 

 

 

 

 

 

4/27/99

4/27/09

Common Stock

4,000

 

4,000

D

 

Option*

$15.875

 

 

 

 

 

 

4/25/00

4/25/10

Common Stock

4,000

 

4,000

D

 

Option*

$21.49

 

 

 

 

 

 

4/24/01

4/24/11

Common Stock

4,000

 

4,000

D

 

Option*

$26.55

 

 

 

 

 

 

4/23/02

4/23/12

Common Stock

4,000

 

4,000

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explanation of Responses:

(*) Option – Right to Buy

 

 

 

 

Harvey Wollman

** Signature of Reporting Person

 

1-30-03

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.

 

http://www.sec.gov/divisions/corpfin/forms/form5.htm

Last update: 09/03/2002

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