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F O R M 5
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[ ] Check box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
[ ] Form 3 Holdings Reported
[ ] Form 4 Transactions Reported
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OMB APPROVAL
OMB Number
Expires:
Estimated Average Burden
hours per response . . . . . .
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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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1. Name and Address of Reporting Person*
Blocker Darrell E.
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(Last) (First) (Middle)
3105 Brampton Drive
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(Street)
Huntington IN 46750
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(City) (State) (Zip)
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2. Issuer Name and Ticker of Trading Symbol
Northeast Indiana Bancorp, Inc. "NEIB"
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
December 1998
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer (Check all applicable)
[ ] Director
[ ] 10% Owner
[X] Officer (give title below)
[ ] Other (specify below)
Senior Vice President/Chief Financial Officer/Treasurer
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7. Individual or Joint/Group Reporting (Check all applicable)
[X] Form Filed by One Reporting Person
[ ] Form Filed by More than One Reporting Person
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<TABLE>
<CAPTION>
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TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENFICIALLY OWNED
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1. Title of Security (Instr. 3) 2. Transaction Date 3. Transaction Code 4. Securities Acquired (A)
(Month/Day/Year) (Instr. 8) or Disposed of (D)
(Instr. 3, 4 and 5)
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(A) or
Amount (D) Price
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<S> <C> <C> <C> <C> <C>
Common Stock 11/23/98 J 1,137 A N/A
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Common Stock 11/23/98 J 198 A N/A
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Common Stock 11/23/98 J 10 A N/A
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Common Stock 11/23/98 J 421 A N/A
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Common Stock * V 1,244 A N/A
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</TABLE>
<PAGE>
<TABLE>
<CAPTION>
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TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENFICIALLY OWNED -- Continued
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1. Title of Security (Instr. 3) 5. Amount of Securities 6. Ownership Form: 7. Nature of Indirect
Beneficially Owned At Direct (D) or Beneficial
End of Issuer's Fiscal Indirect (I) Ownership
Year (Inst. 3 and 4) (Instr. 4) (Instr. 4)
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<S> <C> <C> <C>
Common Stock 12,507 D
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Common Stock 2,179 I Wife
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Common Stock 110 I Custodian for
son
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Common Stock I ESOP
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Common Stock 5,865 I ESOP
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</TABLE>
*
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<TABLE>
<CAPTION>
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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 Date 4. Transaction Code 5. Number of Derivative
(Instr. 3) Of Exercise (Month/Day/Year) (Instr. 8) Securities Acquired (A)
Price of or Disposed of (D)
Derivative (Instr. 3, 4, and 5)
Security
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(A) (D)
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<S> <C> <C> <C> <C> <C> <C>
Employee Stock Option
"Right to Buy" 11/23/98 J 1964
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</TABLE>
<TABLE>
<CAPTION>
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TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTION, CONVERTIBLE SECURITIES) -- Continued
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1. Title of Derivative Security 6. Date 7. Title and 8. Price of
(Instr. 3) Exercisable Amount of Derivavtive
and Underlying Security
Expiration Securities (Instr. 5)
Date (Month/ (Instr. 3
Day/Year) and 4)
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Date Expira- Amount or
Exer- tion Number
cisable Date Title of Shares
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<S> <C> <C> <C> <C> <C>
Employee Stock Option
"Right to Buy" 1/15/97 1/15/07 Common Stock 21,603
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</TABLE>
<PAGE>
<TABLE>
<CAPTION>
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TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTION, CONVERTIBLE SECURITIES) -- Continued
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1. Title of Derivative Security 9. Number of Derivative 10. Ownership of 11. Nature of Indirect
(Instr. 3) Securities Beneficially Derivative Security: Beneficial
Owned at End of Year Direct (D) or Ownership
(Instr. 4) Indirect (I) (Instr. 4) (Instr. 4)
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<S> <C> <C> <C>
Employee Stock Option
"Right to Buy" 21,603 D
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</TABLE>
Explanation of Responses:
*Allocation of shares of stock from ESOP as of 12/31/98 and reported by the ESOP
administrator to the Company on or about January 19, 1999
J = Stock dividend -- 10% paid - 11/23/98
/s/Darrell E. Blocker 2/12/99
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Signature of Reporting Person Date
**Intentional misstatements or ommissions of facts constitute Federal Criminal
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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
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