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OMB Number: 3235-0167
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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 15
CERTIFICATION AND NOTICE OF TERMINATION OF REGISTRATION UNDER SECTION 12(g) OF
THE SECURITIES EXCHANGE ACT OF 1934 OR SUSPENSION OF DUTY TO FILE REPORTS UNDER
SECTIONS 13 AND 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934.
Commission File Number 333-75317
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Union State Bank Key Employees' Supplemental Diversified Investment Plan
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(Exact name of registrant as specified in its charter)
100 Dutch Hill Road, Orangeburg, NY 10962
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(Address, including zip code, and telephone number, including area code, of
registrant's principal executive offices)
Employee benefit plan interests
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(Title of each class of securities covered by this Form)
None
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(Titles of all other classes of securities for which a duty to file
reports under section 13(a) or 15(d) remains)
Please place an X in the box(es) to designate the appropriate rule
provision(s) relied upon to terminate or suspend the duty to file reports:
Rule 12g-4(a)(1)(i) |X| Rule 12h-3(b)(1)(i) |X|
Rule 12g-4(a)(1)(ii) |_| Rule 12h-3(b)(1)(ii) |_|
Rule 12g-4(a)(2)(i) |_| Rule 12h-3(b)(2)(i) |_|
Rule 12g-4(a)(2)(ii) |_| Rule 12h-3(b)(2)(ii) |_|
Rule 15d-6 |_|
Approximate number of holders of records as of the certification or notice
date: 5
Pursuant to the requirements of the Securities Exchange Act of 1934, Union
State Bank Key Employees' Supplemental Investment Plan has caused this
certification/notice to be signed on its behalf by the undersigned duly
authorized person.
Date: 4/05/99 By: /s/ Edwin T. Markham
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Edwin T. Markham, Counsel
Instruction: This form is required by Rules 12g-4, 12h-3 and 15d-6 of the
General Rules and Regulations under the Securities Exchange Act of 1934. The
registrant shall file with the Commission three copies of Form 15, one of which
shall be manually signed. It may be signed by an officer of the registrant, by
counsel or by any other duly authorized person. The name and title of the person
signing the form shall be typed or printed under the signature.
Potential persons who are to respond to the collection of infor-
SEC 2069 (3-99) mation contained in this form are not required to respond unless
the form displays a currently valid OMB control number.
