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FORM 5 OMB Approval
U.S. SECURITIES AND EXCHANGE COMMISSION --------------------------
[ ] Check this box if no longer WASHINGTON, D.C. 20549 OMB Number
subject to Section 16. Form Expires:
4 or Form 5 obligations may ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Estimated average burden
continue. See Instruction 1(b). hours per response
[ ] Form 3 Holdings Reported Filed pursuant to Section 16(a) of the Securities
[ ] Form 4 Transactions Reported and 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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1. Name and Address of Reporting Person 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person
to Issuer (Check all applicable)
Rogers Robert T. Horizon Bancorp Inc of WV __X___ Director _____ 10% Owner
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(Last) (First) (Middle) 3. IRS or Social 4. Statement for _____ Other (specify below)
Security Number Month/Year
HC77 Buck Rt Box 1 of Reporting 8/94
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(Street) 5. If Amendment, Date ------------------------
of Original (Month/Year)
Hinton WV 25951 235547804
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(City) (State) (Zip) Table I - Non Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1. Title of Security 2.Transaction 3.Transaction 4.Securities Acquired (A) 5.Amount of 6.Owner 7.Nature
(Instr. 3) Date Code or Disposed of (D) Securities ship of
(Month/Day/ (Instr. 8) (Instr. 3, 4, and 5) Beneficially Form: Indirect
Year) Owned at End Direct Bene-
----------------------------------------- of Issuer's (D) or ficial
Amount (A) Price Fiscal Year Indirect Owner-
or (Instr. 3 (I) ship
(D) and 4) (Instr.4)(Instr.4)
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Common Stock 17542* D Self
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Common Stock 650* I Spouse
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Common Stock 8-5-94 P4 900 A $29 1800* D Joint
with
spouse
(street
name)
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Common Stock 8-5-94 P4 100 A $29 200* I Spouse
(street
name)
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Reminder: Report on a separate line for each class of securities beneficially owned, directly or indirectly. (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 Security 2.Conversion 3.Transaction 4.Transaction 5.Number of 6.Date Exer- 7.Title and Amount
(Instr. 3) or Exercise Date Code Derivative cisable and of Underlying
Price of (Instr. 8) Securities Expiration Date Securities
Derivative (Month/Day/ Acquired (A) (Month/Day/Year) (Instr. 3 and 4)
Security Year) or Disposed
of (D) --------------------------------------
(Instr. 3, Date Expir- Amount or
4, and 5) Exer- ation Title Number of
-------------- cisable Date Shares
(A) (D)
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8.Price of 9.Number of 10.Ownership 11.Nature of
Derivative Derivative Form of Indirect
Security Securities Derivative Beneficial
(Instr. 5) Beneficially Security; Ownership
Owned at End Direct (D) or (Instr. 4)
of Year Indirect (I)
(Instr. 4) (Instr. 4)
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Explanation of Responses:
* Increase in share amounts reflect a 100% stock dividend payable
12-15-96 to shareholders of record on 12-1-96 and also reflects ROBERT T. ROGERS 2/10/97
shares acquired pursuant to Horizon Bancorp Inc's dividend ------------------------------------ -----------------
reinvestment plan. *Signature of Reporting Person Date
POA on file
** 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.
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