5 1 j7346_5.htm 5

FORM 5

 

 X  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

Mengedoth,        Donald               R.

(Last)            (First)              (Middle)



P.O. Box 4530

(Street)



Edwards,            CO          81632-4530

(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

 

 

 

 

 

 

198,545

D

 

 

 

 

 

 

 

 

0(a)

I

SERP

 

 

 

 

 

 

 

20,898(b)

I

401(k)

8.20% Cumulative Capital Security
(CFBXZ)

 

 

 

 

 

 

5,000

I

IRA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)           Includes 15,074 shares sold, not previously reported.

(b)           Includes 614 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. Conver sion 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 at End of Year
(Instr. 4)

10.Ownership of Derivative Security:
Direct (D) or Indirect (I)
(Instr. 4)

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

(A)

(D)

Date
Exercisable

Expiration
Date

Title

Amount or Number of Shares

Option*

$14.00

 

 

 

 

 

(1)

2/8/10

Common Stock

90,000

 

30,000

D

 

Option*

25.87

 

 

 

 

 

(2)

2/2/09

Common Stock

49,913(y)

 

49,913(y)

D

 

Option*

$25.87

 

 

 

 

 

(3)

2/8/10

Common Stock

41,816(z)

 

41,816(z)

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explanation of Responses:

 (*)          Option — Right to Buy

(1)                                 The option becomes exercisable with respect to one-third of the shares per year, commencing one year from the date of grant, which is also nine years prior to the expiration date.

(2)                                 Option acquired via reload feature of 2/2/99 $19.5625 option grant, (y) including 4,543 shares sold at exercise to facilitate withholding, relative to non-qualified options, not previously reported.

(3)                                 Option acquired via reload feature of 2/8/00 $14.00 option grant, (z) including 9,346 shares sold at exercise to facilitate withholding, relative to non-qualified options, not previously reported..

 

 

 

 

 

 

/s/ Galen O. Skarphol***

** Signature of Reporting Person

 

2-11-03

Date

 

**         Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
             See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).

 

***      Attorney-in-fact, pursuant to power-of-attorney dated September 5, 2002.

 

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