0001144204-11-028024.txt : 20110511 0001144204-11-028024.hdr.sgml : 20110511 20110511141451 ACCESSION NUMBER: 0001144204-11-028024 CONFORMED SUBMISSION TYPE: SC 13G PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20110511 DATE AS OF CHANGE: 20110511 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: Edstam David CENTRAL INDEX KEY: 0001383912 FILING VALUES: FORM TYPE: SC 13G MAIL ADDRESS: STREET 1: 5023 BRUCE AVENUE CITY: EDINA STATE: MN ZIP: 55424 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: Skagit State Bancorp, Inc. CENTRAL INDEX KEY: 0001366986 STANDARD INDUSTRIAL CLASSIFICATION: STATE COMMERCIAL BANKS [6022] IRS NUMBER: 205048602 STATE OF INCORPORATION: WA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13G SEC ACT: 1934 Act SEC FILE NUMBER: 005-81883 FILM NUMBER: 11831427 BUSINESS ADDRESS: STREET 1: 301 E. FAIRHAVEN AVENUE CITY: BURLINGTON STATE: WA ZIP: 98233 BUSINESS PHONE: 360-755-0411 MAIL ADDRESS: STREET 1: PO BOX CITY: BURLINGTON STATE: WA ZIP: 98233 SC 13G 1 v221975_sc13g.txt SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 SCHEDULE 13G (Rule 13d-102) INFORMATION TO BE INCLUDED IN STATEMENTS FILED PURSUANT TO RULES 13d-1(b), (c), AND (d) AND AMENDMENTS THERETO FILED PURSUANT TO RULE 13d-2 (Amendment No._________)* Skagit State Bancorp, Inc. -------------------------------------------------------------------------------- (Name of Issuer) Common Stock, no par value -------------------------------------------------------------------------------- (Title of Class of Securities) 830462 10 7 -------------------------------------------------------------------------------- (CUSIP Number) May 8, 2011 -------------------------------------------------------------------------------- (Date of Event Which Requires Filing of this Statement) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: |_| Rule 13d-1(b) |X| Rule 13d-1(c) |_| Rule 13d-1(d) ---------- * The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). CUSIP No. 830462 10 7 13G Page 2 of 5 Pages -------------------------------------------------------------------------------- 1. NAME OF REPORTING PERSONS David R. Edstam -------------------------------------------------------------------------------- 2. CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) |_| (b) |_| -------------------------------------------------------------------------------- 3. SEC USE ONLY -------------------------------------------------------------------------------- 4. CITIZENSHIP OR PLACE OF ORGANIZATION USA -------------------------------------------------------------------------------- NUMBER OF 5. SOLE VOTING POWER SHARES BENEFICIALLY 0 OWNED BY -------------------------------------------------------------- EACH 6. SHARED VOTING POWER REPORTING PERSON 49,925 WITH -------------------------------------------------------------- 7. SOLE DISPOSITIVE POWER 0 -------------------------------------------------------------- 8. SHARED DISPOSITIVE POWER 49,925 -------------------------------------------------------------------------------- 9. AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 49,925 SHARES -------------------------------------------------------------------------------- 10. CHECK IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES (SEE INSTRUCTIONS) |_| -------------------------------------------------------------------------------- 11. PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9) 8.5% -------------------------------------------------------------------------------- 12. TYPE OF REPORTING PERSON* IN -------------------------------------------------------------------------------- CUSIP No. 830462 10 7 13G Page 3 of 5 Pages -------------------------------------------------------------------------------- Item 1(a). Name of Issuer: Skagit State Bancorp, Inc. -------------------------------------------------------------------------------- Item 1(b). Address of Issuer's Principal Executive Offices: 301 East Fairhaven Avenue, Burlington, WA 98233 -------------------------------------------------------------------------------- Item 2(a). Name of Person Filing: David R. Edstam -------------------------------------------------------------------------------- Item 2(b). Address of Principal Business Office, or if none, Residence: 5023 Bruce Avenue, Edina, MN 55424 -------------------------------------------------------------------------------- Item 2(c). Citizenship: Mr. Edstam is a citizen of the United States. -------------------------------------------------------------------------------- Item 2(d). Title of Class of Securities: Common Stock, No par value -------------------------------------------------------------------------------- Item 2(e). CUSIP Number: 830462 10 7 -------------------------------------------------------------------------------- Item 3. If This Statement is Filed Pursuant to ss.ss. 240.13d-1(b), or 240.13d-2(b) or (c), check whether the person filing is a: (a) |_| Broker or dealer registered under Section 15 of the Act (15 U.S.C. 78o); (b) |_| Bank as defined in Section 3(a)(6) of the Act (15 U.S.C. 78c); (c) |_| Insurance company as defined in Section 3(a)(19) of the Act (15 U.S.C. 78c); (d) |_| Investment company registered under Section 8 of the Investment Company Act of 1940 (15 U.S.C. 80a-8); (e) |_| An investment adviser in accordance with ss. 240.13d-1(b)(1)(ii)(E); (f) |_| An employee benefit plan or endowment fund in accordance with ss. 240.13d-1(b)(1)(ii)(F); (g) |_| A parent holding company or control person in accordance with ss. 240.13d-1(b)(1)(ii)(G); (h) |_| A savings association as defined in Section 3(b) of the Federal Deposit Insurance Act (12 U.S.C. 1813); (i) |_| A church plan that is excluded from the definition of an investment company under Section 3(c)(14) of the Investment Company Act (15 U.S.C. 80a-3); (j) |_| A non-U.S. institution in accordance with ss. 240.13d-1(b)(1)(ii)(J); (k) |_| Group, in accordance with ss. 240.13d-1(b)(1)(ii)(K). If filing as a non-U.S. institution in accordance with ss. 240.13d-1(b)(1)(ii)(J), please specify the type of institution: __________________. CUSIP No. 830462 10 7 13G Page 4 of 5 Pages Item 4. Ownership. Provide the following information regarding the aggregate number and percentage of the class of securities of the issuer identified in Item 1. (a) Amount beneficially owned: The Reporting Person holds 18,795 shares in the David R. Edstam Revocable Trust dtd 5/22/06, of which he is the grantor and a trustee. The remaining shares (31,130 in the aggregate) are held by various trusts for the benefit of members of the Reporting Person's family and of which the Reporting Person is a trustee. -------------------------------------------------------------------- (b) Percent of class: 8.5% (Based upon 588,346 shares outstanding on March 18, 2011 as reported by in the Issuer's most recent proxy statement) -------------------------------------------------------------------- (c) Number of shares as to which such person has: (i) Sole power to vote or to direct the vote: 0 (ii) Shared power to vote or to direct the vote: 49,925 (iii) Sole power to dispose or to direct the disposition of: 0 (iv) Shared power to dispose or to direct the disposition of: 49,925 -------------------------------------------------------------------- Item 5. Ownership of Five Percent or Less of a Class. If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to the beneficial owner of more than 5 percent of the class of securities, check the following: |_| -------------------------------------------------------------------------------- Item 6. Ownership of More Than Five Percent on Behalf of Another Person. 31,130 shares are held in 5 different trusts for the benefit of members of the Reporting Person's family and for which the Reporting Person is a trustee. -------------------------------------------------------------------------------- Item 7. Identification and Classification of the Subsidiary Which Acquired the Security Being Reported on by the Parent Holding Company or Control Person. N/A -------------------------------------------------------------------------------- Item 8. Identification and Classification of Members of the Group. N/A -------------------------------------------------------------------------------- Item 9. Notice of Dissolution of Group. N/A -------------------------------------------------------------------------------- Item 10. Certifications. (a) Not applicable (b) Not applicable (c) By signing below I certify that, to the best of my knowledge and belief, the securities referred to above were not acquired and are not held for the purpose of or with the effect of changing or influencing the control of the issuer of the securities and were not acquired and are not held in connection with or as a participant in any transaction having that purpose or effect. SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. Dated: May 10, 2011 /s/ David R. Edstam ---------------------------------------- David R. Edstam