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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 OMB APPROVAL
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP ---------------------------
obligations may OMB Number: 3235-0362
continue. See Filed pursuant to Section 16(a) of the Securities Expires: September 30, 1998
Instruction 1(b) Exchange Act of 1934, Estimated average burden
/ / Form 3 Holdings Section 17(a) of the Public Utility hours per response......1.0
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)
Calabrese Christa N. Success Bancshares, Inc. (SXNB) X Form filed by One Reporting
---- Person
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
c/o Success Bancshares, Inc. Person, if an Entity
Tri-State International - Suite 300 (Voluntary) 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)
Executive Vice President and Chief
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Lending Officer 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)
Common Stock 7/1/99 J(1) 632 A 9.125 1,432 D
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(1) Acquisition pursuant to Employee Stock Purchase Plan.
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(Over)
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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 (2) 9/23/08 Common Stock 10,000 13.875
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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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10,000 D
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Explanation of Responses:
(2) Exercisable in increments of 2,500 shares on each of September 23, 1999, 2000, 2001 and 2002.
/s/ CHRISTA N. CALABRESE May 3, 2000
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Signature of Reporting Person(1) Date
Christa N. Calabrese
(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.
If space provided is insufficient, see Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the
form display a currently valid OMB number.
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