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FORM 5
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/ / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION
longer subject to WASHINGTON, DC 20549
Section 16. Form
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
obligations may
continue. See Filed pursuant to Section 16(a) of the Securities
Instruction 1(b) Exchange Act of 1934,
/ / Form 3 Holdings Section 17(a) of the Public Utility
Reported Holding Company Act of 1935 or Section 30(f) of
/ / Form 4 the Investment Company Act
Transactions of 1940
Reported
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1. Name and Address of Reporting Person 2. Issuer Name and Ticker or Trading Symbol 7. Individual or Joint/Group Filing
(Check applicable line)
CIB Marine Bancshares, Inc.(not listed) x Form filed by One Reporting
(formerly known as Central Illinois ---- Person
Bancorp, Inc.) Form Filed by More Than One
Straka Donald J. ---- Reporting Person
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(Last) (First) (Middle) 3. IRS Identification 4. Statement for
Number of Reporting Month/Year
Person , if an Entity
(Voluntary)
N53 W14147 Invery Drive December, 1999
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(Street) 5. If Amendment,
Menomonee Falls, WI 53051 Date of Original
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(City) (State) (Zip)
6. Relationship of Reporting Person to
Issuer (Check all applicable)
Director 10% Owner
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X Officer (give Other (Specify
---- title --- below)
below)
Senior Vice President, Secretary and
General Counsel
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TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature
(Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In-
Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct
(Instr. 8) End of Issuer's Direct Benefi-
(Month/ Fiscal Year (D) or cial
Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner-
Year) Amount (A) or Price (I) ship
(D) (Instr. 4) (Instr.
4)
Common stock 5 D
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Common stock 32 (1) I By SIG, a
general
partnership
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Common stock 3.5 (2) I By ESOP
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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 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price
Security sion or action action Derivative cisable and of Underlying of
(Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv-
Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative
Deriv- Day/ Disposed of (D) (Month/Day/ Secur-
ative Year) (Instr. 3, 4, Year) ity
Security and 5) (Instr. 5)
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Date Expira- Amount or
--------------- Exer- tion Title Number of
(A) (D) cisable Date Shares
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Employee Stock Option $2,059.64 (3) 9/24/07 Common 46
(right to buy)(3) stock
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Employee Stock Option $1,960.56 (4) 2/25/08 Common 103
(right to buy)(4) stock
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Employee Stock Option $2,434.48 7/29/99 A 79 (5) 7/29/09 Common 79
(right to buy)(5) stock
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9. Number of 10. Ownership 11. Nature of
Derivative of Derivative Indirect
Securities Security: Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Year (Instr. 4)
(Instr. 4)
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46 D
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103 D
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79 D
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Explanation of Responses:
(1) The reporting person disclaims beneficial ownership of these securities except to /s/ Donald J. Straka 2-7-2000
the extent of his pecuniary interest therein. ------------------------------ --------
(2) Represents shares allocated to the reporting person, at 12/31/99, pursuant to the Signature of Reporting Person
issuer's ESOP.
(3) The employee stock option vests in five equal annual installments which began on
September 24, 1998.
(4) The employee stock option vests in five equal annual installments which began on
February 25, 1999. Page 2
(5) The employee stock option vests in five equal annual installments beginning on
July 29, 2000.
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