-----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, B0po1Mr5feCFbVGWkA5k54af+m9oRzRulYiHVUA7uaBrkdDgr5a1TWhbOOOzAkuK EPBNpm059KhQupiL54oV8Q== 0000927797-05-000031.txt : 20050210 0000927797-05-000031.hdr.sgml : 20050210 20050210144749 ACCESSION NUMBER: 0000927797-05-000031 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20041231 FILED AS OF DATE: 20050210 DATE AS OF CHANGE: 20050210 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: IA 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: 05592433 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 ncbform5-chalstrom_123104ex.xml X0202 5 2004-12-31 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 1 1 0 0 Executive Vice President Common stock, par value $0.01 per share 2710 D Common stock, par value $0.01 per share 512 I 401(k) Trust 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 of the 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-3 (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 2005-02-09 -----END PRIVACY-ENHANCED MESSAGE-----