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OMB APPROVAL
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- -------- OMB Number: 3235-0104
FORM 3 Expires: April 30, 1997
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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 6. If Amendment, Date
Citizens Bancshares, Inc. Statement Trading Symbol of Original
- ---------------------------------------- (Month/Day/Year) MID-AM, INC. (Month/Day/Year)
(Last) (First) (Middle) 5/21/98 ------------------------------------ N/A
10 East Main Street, P.O. Box 247 ---------------------------- 5. Relationship of Reporting ---------------------
- ---------------------------------------- 3. IRS or Social Security Person to Issuer 7. Individual or
(Street) Number of Reporting (Check all applicable) Joint/Group Filing
Person (Voluntary) ----- Director X 10% Owner (Check Applicable
Salineville, Ohio 43945 34-1372535 ----- Officer ----- Other (specify Line)
- -------------------------------------- ---------------------------- (give title below) below) X Form Filed by One
(City) (State) (Zip) Reporting Person
--------------------------- -- Form Filed by More
than One Reporting
Person
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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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
(Print or Type Responses) SEC 1473 (9/96)
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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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Option to purchase Mid-Am, Inc., Mid-Am, Inc.
Common Stock T T Common Stock 4,648,726 TT D
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Explanation of Responses:
T Beneficial ownership of 4,648,726 shares reported hereunder is being reported solely as a result of the Stock Option Agreement,
dated as of May 21, 1998 (the "Stock Option Agreement"), by and between Citizens Bancshares, Inc. and Mid-Am, Inc. The option may
be exercised, in whole or in part, only upon certain events (none of which, as of the date hereof, has occurred), as set forth in
the Stock Option Agreement. The option expires upon certain events, as set forth in the Stock Option Agreement. The option
granted pursuant to the Stock Option Agreement has not yet become exercisable. Citizens Bancshares, Inc. expressly disclaims
ownership of such shares.
** Intentional misstatements or omissions of facts constitute Federal Criminal TT A price per share equal to $27.00 subject to
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). adjustment in certain circumstances.
Note. File three copies of this Form, one of which must be manually signed. By: /s/ MARTY E. ADAMS May 29, 1998
If space provided is insufficient, See Instruction 6 for procedure. ------------------------------- -------------
**Signature of Reporting Person Date
Potential persons who are to respond to the collection of information contained in this Page 2
form are not required to respond unless the form displays a currently valid OMB Number. SEC 1473 (9/96)
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