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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
- ----------- Washington D.C. 20549 --------------------------------
FORM 4 OMB APPROVAL
- ----------- STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP --------------------------------
/ / Check this box if no longer OMB Number: 3235-0287
subject to Section 16. Form 4 or Filed pursuant to Section 16(a) of the Securities Expires: September 30,1998
Form 5 obligations may continue. Exchange Act of 1934, Section 17(a) of the Public Estimated average burden
See Instruction 1(b). Utility Holding Company Act of 1935 or Section hours per response..........0.5
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(s)
to Issuer (Check all applicable)
Rupp Carl F. Tri-County Bancorp, Inc. TRIC __X__Director _____10% Owner
- --------------------------------------------------------------------------------------- _____Officer (give title below)
(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for _____Other (specify below)
Number of Reporting Month/Year
RR 2, Box 299A Person (Voluntary) DEC 1999 ---------------------------------------
- ------------------------------------------- ------------------------------------------------------------
(Street) 5. If Amendment, 7. Individual or Joint/Group Filing
###-##-#### Date of (Check Applicable Line)
Original __X_ Form filed by One Reporting
(Month/Year) Person
____ Form filed by More than One
Torrington WY 82240 Reporting Person
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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. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of
(Instr. 3) action action or Disposed of (D) Securities Form: indirect
Date Code (Instr. 3, 4 and 5) Beneficially Direct (D) Beneficial
Month/ ---------------------------------------- Owned at or Indirect (I) Ownership
Day/Yr Code V Amount (A)or(D) Price End of Month (Instr. 4) (Instr. 4)
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Common Stock 12/99 J* 3,741 A $5.00 21,000 D
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* Stock Options exercised
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
*If the form is filed by more than one reporting person, see Instruction 4(b)(v).
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FORM 4 (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 Derivative 6. Date Exercisable
(Instr. 3) or Exercise Date Code Securities Acquired(A) and Expiration
Price of (Month/ (Instr. 8) or Disposed of (D) (Month/Day/
Derivative Day/Year) (Instr. 3, 4 and 5) Year)
Security ----------------------------------------------------------------
Code V (A) (D) Date Expira-
Exer- tion
cisable Date
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Stock Option-Right to buy $5.00 12/99 J* 3,741 9/96 9/01
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7. Title and Amount of 8. Price of 9. Number of derivative 10. Ownership Form 11. Nature of Indirect
Underlying Securities Derivative Security Securities Beneficially of Derivative Beneficial Ownership
(Instr. 3 and 4) (Instr. 5) Owned at End of Month Security: Direct (D) (Instr. 4)
(Instr.4) or Indirect(I)
(Instr. 4)
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Common 3,734 D
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Explanation of Responses:
/s/Carl F. Rupp December 17, 1999
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**Signature of Reporting Person Date
* Intentional misstatement 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 is insufficient,
See Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not required to respond
unless the form displays a currently valid OMB Number.
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