-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, EybgBhsbn5BoPSYDHTbf7ghv68dp0jn4Tl3UZjQLpZZiR7i8JVe9neH6/y8dIjPU cI4W/hNN62eMzP0n9l0LYA== 0000927797-04-000039.txt : 20040130 0000927797-04-000039.hdr.sgml : 20040130 20040130170114 ACCESSION NUMBER: 0000927797-04-000039 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20031231 FILED AS OF DATE: 20040130 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: NORTH CENTRAL BANCSHARES INC CENTRAL INDEX KEY: 0001005188 STANDARD INDUSTRIAL CLASSIFICATION: SAVINGS INSTITUTION, FEDERALLY CHARTERED [6035] IRS NUMBER: 421449849 STATE OF INCORPORATION: IA FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 825 CENTRAL AVE STREET 2: C/O FIRST FED SAVINGS BANK OF FT DODGE CITY: FORT DODGE STATE: I0 ZIP: 50501 BUSINESS PHONE: 5155767531 MAIL ADDRESS: STREET 1: 825 CENTRAL AVENUE CITY: FORT DODGE STATE: IA ZIP: 50501 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: CHALSTROM C THOMAS CENTRAL INDEX KEY: 0001195964 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-27672 FILM NUMBER: 04556624 BUSINESS ADDRESS: STREET 1: C/O NORTH CENTRAL BANCSHARES INC STREET 2: 825 CENTRAL AVE. PO BOX 1237 CITY: FORT DODGE STATE: IA ZIP: 50501 BUSINESS PHONE: 5155767531 MAIL ADDRESS: STREET 1: C/O NORTH CENTRAL BANCSHARES INC STREET 2: 825 CENTRAL AVE PO BOX 1237 CITY: FORT DODGE STATE: IA ZIP: 50501 5 1 ncbform5chalstrom_12-03ex.xml X0201 5 2003-12-31 0 0 0 0001005188 NORTH CENTRAL BANCSHARES INC FFFD 0001195964 CHALSTROM C THOMAS C/O NORTH CENTRAL BANCSHARES INC 825 CENTRAL AVE. PO BOX 1237 FORT DODGE IA 50501 0 1 0 0 Executive Vice President Common stock, par value $0.01 per share 2710 D Common stock, par value $0.01 per share 383 I 401k Trust Stock option (right to buy) 12.375 2001-09-21 2006-09-21 Common stock 3500 3500 D Stock option (right to buy) 19.25 2003-01-30 2008-01-30 Common stock 6500 6500 D Reflects total shares allocable to the reporting person pursuant to shares of stock held by the Bank of New York, as trustee of the North Central Bancshares, Inc. Stock Fund of the First Federal Savings Bank of Iowa 401(k) Plan. Pursuant to rule 16a- (f)(1)(i)(B) under the Securities and Exchange Act of 1934, as amended, only end-of-period holdings, rather than specific transactions, are reported. /s/C. Thomas Chalstrom 2004-01-14 -----END PRIVACY-ENHANCED MESSAGE-----