<PAGE>
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 5
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
( ) Check this box if no longer subject to Section 16. Form 4 or
Form 5 obligations may continue. See Instructions 1(b).
(X) Form 3 Holdings Reported.
( ) Form 4 Transactions Reported.
1. Name and Address of Reporting Person:
W. Scott Blake
731 N. Jackson Street, Suite 400
Milwaukee, WI 53202
2. Issuer Name and Ticker or Trading Symbol:
Central Illinois Bancorp, Inc. (not listed)
3. IRS or Social Security Number of Reporting Person (Voluntary):
4. Statement for Month/Year:
December, 1998
5. If Amendment, Date of Original (Month/Year):
6. Relationship of Reporting Person(s) to Issuer (Check all
applicable):
(x) Director ( ) 10% Owner ( ) Officer (give title below) ( )
Other (specify below)
7. Individual or Joint/Group Filing (Check Applicable Line):
(x) Form filed by One Reporting Person
( ) Form filed by More than One Reporting Person<PAGE>
<TABLE>
<CAPTION>
Table I -- Non-Derivative Securities Acquired,
Disposed of, or Beneficially Owned
<S> <C> <C> <C> <C> <C> <C>
5. Amount
of Securities
Beneficially 6. Owner- 7. Nature of
2. Trans- Owned at End ship Form: Indirect
1. Title of action 3. Trans- 4. Securities Acquired (A) of Month Direct (D) or Beneficial
Security Date (Month/ action Code or Disposed of (D) (Instr. 3 Indirect (I) Ownership
(Instr. 3) Day/Year) (Instr. 8) (Instr. 3, 4 and 5) and 4) (Instr. 4) (Instr. 4)
----------- ------------ ----------- -------------------------- ------------- ------------- ------------
Code V Amount (A)or(D) Price
</TABLE>
<TABLE>
<CAPTION>
Table II -- Derivative Securities Acquired,
Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
9. 10.
Number of Ownership
5. Deri- Form of
2. Number of vative Deriva-
1. Conver- Derivative 6. Securities tive 11.
Title sion or Securities Date 7. 8. Benefi- Security: Nature
of Exercise 3. Trans- 4. Acquired (A) Exercis- Title Price of cially Direct (D) of
Deri- Price of action Trans- or Disposed able and and Amount of Deri- Owned or In- Indirect
vative Deriva- Date action of (D) Expiration Underlying vative at End of direct Beneficial
Security tive (Month/ Code (Instr. 3, Date (Month/ Securities Security Month (I) Ownership
(Instr. 3) Security Day/Year) (Instr. 8) 4 and 5) Day/Year) (Instr. 3 and 4) (Instr. 5)(Instr. 4)(Instr. 4) (Instr. 4)
Code V (A) (D) Date Expir- Title Amount or
Exer- ation Number of
cis- Date Shares
able
Director $1,274.91 1/1/95 3 (1) (1) 1/1/05 Common 10 10 D
Stock Stock
Option
(right to
buy) (1)
Director $1,630.51 4/25/96 3 (2) (2) 4/25/06 Common 13 13 D
Stock Stock
Option
(right to
buy) (2)
Director $1,960.56 2/25/98 3 (3) (3) 2/25/08 Common 100 100 D
Stock Stock
Option
(right to
buy) (3)
/TABLE
<PAGE>
Explanation of Responses:
(1) Five shares of the director stock option dated 1/1/95 vested on
January 1, 1998 and the remaining five shares will vest on
January 1, 2000.
(2) The director stock option dated 4/25/96 vests in five equal
annual installments which began on April 25, 1997.
(3) The director stock option dated 2/25/98 vests in five equal
annual installments beginning on February 25, 1999.
SIGNATURE OF REPORTING PERSON:
W. Scott Blake<PAGE>
DATE: February 10, 1999
