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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
- ----------- Washington D.C. 20549 --------------------------------
FORM 5 OMB APPROVAL
- ----------- ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP --------------------------------
/ / Check this box if no longer OMB Number: 3235-0362
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..........1.0
/ / Form 3 Holdings Reported 30(f) of the Investment Company Act of 1940 --------------------------------
/ / Form 4 Transactions Reported
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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)
Larry C. Goddard Tri-County Bancorp, Inc. TRIC __X__Director _____10% Owner
- --------------------------------------------------------------------------------------- __X__Officer (give title below)
(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for _____Other (specify below)
Number of Reporting Month/Year Chairman of the Board
2625 East A Street Person (Voluntary) DEC 1998 ------------------------------------------
- ------------------------------------------- ------------------------------------------------------------
(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 Year (Instr. 4) (Instr. 4)
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Common Stock 12/07/98 S 10,372 D $14.00
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Common Stock 9/98 J** 1,196 A -- 20,737 D
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Common Stock 871 I Spouse
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** Vesting of MSBP
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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 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 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 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 Year Security: Direct (D) (Instr. 4)
(Instr.4) or Indirect(I)
(Instr. 4)
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Common 14,950 D
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Explanation of Responses:
/s/Larry C. Goddard February 12, 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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