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FORM 5
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/ / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION
longer subject to WASHINGTON, DC 20549
Section 16. Form
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
obligations may
continue. See Filed pursuant to Section 16(a) of the Securities
Instruction 1(b) Exchange Act of 1934,
/ / Form 3 Holdings Section 17(a) of the Public Utility
Reported Holding Company Act of 1935 or Section 30(f) of
/ / Form 4 the Investment Company Act
Transactions of 1940
Reported
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1. Name and Address of Reporting Person(1) 2. Issuer Name and Ticker or Trading Symbol 7. Individual or Joint/Group Filing
(Check applicable line)
X Form filed by One Reporting
---- Person
Tragasz Ronald W. Success Bancshares, Inc. (SXNB) Form Filed by More Than One
---- Reporting Person
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(Last) (First) (Middle) 3. IRS Identification 4. Statement for
Number of Reporting Month/Year
Person, if an Entity
c/o Success Bancshares, Inc. (Voluntary)
100 Tri-State International - Suite 300 7/99
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(Street) 5. If Amendment,
P.O. Box 1499 Date of Original
Lincolnshire, IL 60069-1499 (Month/Year)
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(City) (State) (Zip)
6. Relationship of Reporting Person to
Issuer (Check all applicable)
Director 10% Owner
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X Officer (give Other (Specify
---- title --- below)
below)
Senior Vice President and Cashier
of Success National Bank
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TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature
(Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In-
Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct
(Instr. 8) End of Issuer's Direct Benefi-
(Month/ Fiscal Year (D) or cial
Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner-
Year) Amount (A) or (D) Price (I) ship
(Instr. 4) (Instr.
4)
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Common Stock 7/1/99 J(1) 171 A 9.125 171 D
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(1) Acquisition pursuant to Employee Stock Purchase Plan.
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FORM 5 (CONTINUED) 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 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price
Security sion or action action Derivative cisable and of Underlying of
(Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv-
Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative
Deriv- Day/ Disposed of (D) (Month/Day/ Secur-
ative Year) (Instr. 3, 4, Year) ity
Security and 5) (Instr. 5)
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Date Expira- Amount or
--------------- Exer- tion Title Number of
(A) (D) cisable Date Shares
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Stock Option 4/28/99 4/28/09 Common 3,000 10.125
Stock
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Stock Option (2) 9/23/08 Common 5,000 13.875
Stock
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9. Number of 10. Ownership 11. Nature of
Derivative of Derivative Indirect
Securities Security: Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Year (Instr. 4)
(Instr. 4)
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3,000 D
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5,000 D
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Explanation of Responses:
(2) Exercisable in increments of 1,250 shares on each of September 23, 1999, 2000, 2001 and 2002.
/s/ Ronald W. Tragasz May 3, 2000
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Signature of Reporting Person(1) Date
Ronald W. Tragasz
(1) 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. Page 2
If space provided is insufficient, see Instruction 6 for procedure.
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