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OMB APPROVAL
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- -------- OMB Number: 3235-0104
FORM 3 Expires: February 1, 1994
- -------- Estimated average burden
hours per response .... 0.5
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U.S. SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, DC 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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(f) of the
Investment Company Act of 1940
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<S> <C> <C> <C>
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1. Name and Address of Reporting Person 2. Date of Event Requiring 4. Issuer Name and Ticker or
BAZEMORE JACK G. Statement Trading Symbol
- ---------------------------------------- (Month/Day/Year) HORIZON BANCORP INC. OF WV
(Last) (First) (Middle) 8/30/96 ------------------------------------
58 MEADOWLARK DRIVE ---------------------------- 5. Relationship of Reporting 6. If Amendment, Date
- ---------------------------------------- 3. IRS or Social Security Person to Issuer of Original
(Street) Number of Reporting (Check all applicable) (Month/Day/Year)
Person (Voluntary) X
ONA WV 25545 ###-##-#### ----- Director ----- 10% Owner 8/30/96
- -------------------------------------- ---------------------------- ----- Officer ----- Other (specify
(City) (State) (Zip) (give title below) below)
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TABLE 1 -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect
(Instr. 4) Beneficially Owned Direct (D) or Beneficial
(Instr. 4) Indirect (I) Ownership (Instr. 5)
(Instr. 5)
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COMMON STOCK 333* D SELF
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COMMON STOCK 303* D JOINT WITH SPOUSE
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
(Print or Type Responses) SEC 1473 (8/92)
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FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<S> <C> <C> <C> <C> <C>
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1. Title of Derivative Security 2. Date 3. Title and Amount of 4. Conver- 5. Owner- 6. Nature of Indirect
(Instr. 4) Exercisable and Securities Underlying sion or ship Beneficial Ownership
Expiration Date Derivative Security Exercise Form of (Instr. 5)
(Month/Day/ (Instr. 4) Price of Deriv-
Year) Deri- ative
vative Security:
Security Direct
------------------------------------------------- (D) or
Date Expira- Amount or Indirect (I)
Exercis- tion Title Number (Instr. 5)
able Date of Shares
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Explanation of Responses:
*This corrects the amount initially reported on Form 3 as a result of the merger
between Horizon Bancorp Inc and Twentieth Bancorp to accurately reflect the
exchange ratio of 1.01 (rather than 1.0) shares of Horizon Bancorp Inc. stock
for each share of Twentieth Bancorp in the merger. This does not reflect the
100% stock dividend payable 12-15-96 to shareholders of record on 12-1-96.
/s/ JACK G. BAZEMORE 2/4/97
**Intentional misstatements or omissions of facts constitute Federal Criminal ------------------------------- -------------
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). **Signature of Reporting Person Date
Note. File three copies of this Form, one of which must be manually signed. POA on file. Page 2
If space provided is insufficient, See Instruction 6 for procedure. SEC 1473 (8/92)
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