-----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, K9v+/ZXCHHC8DnAa/vuQBp9TCDlsD+2ti7B3bZ/LzNNrQK5rdoSIItfssPz9S++S iSpvKeFvxZvdyU7/67A/ng== 0000914317-03-000368.txt : 20030207 0000914317-03-000368.hdr.sgml : 20030207 20030207151657 ACCESSION NUMBER: 0000914317-03-000368 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030205 FILED AS OF DATE: 20030207 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: JOHNSON GORDON C CENTRAL INDEX KEY: 0001212386 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: P.O. BOX 1868 CITY: LAKEVILLE STATE: CT ZIP: 06039 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: SALISBURY BANCORP INC CENTRAL INDEX KEY: 0001060219 STANDARD INDUSTRIAL CLASSIFICATION: SAVINGS INSTITUTION, FEDERALLY CHARTERED [6035] IRS NUMBER: 061514263 STATE OF INCORPORATION: CT FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-24751 FILM NUMBER: 03544641 BUSINESS ADDRESS: STREET 1: 5 BISSELL ST CITY: LAKEVILLE STATE: CT ZIP: 06039-1868 BUSINESS PHONE: 8604359801 MAIL ADDRESS: STREET 1: 5 BISSELL ST CITY: LAKEVILLE STATE: CT ZIP: 06039-1868 5 1 form5johnson49299salisbury.txt UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 5 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(h) of the Investment Company Act of 1940 |_| 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 ________________________________________________________________________________ 1. Name and Address of Reporting Person* Johnson Gordon Charles - -------------------------------------------------------------------------------- (Last) (First) (Middle) P.O. Box 732 - -------------------------------------------------------------------------------- (Street) Lakeville CT 06039 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol Salisbury Bancorp, Inc. (SAL) ________________________________________________________________________________ 3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year December 2002 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) |X| Director |_| 10% Owner |_| Officer (give title below) |_| Other (specify below) ____________________________________________________________________ ________________________________________________________________________________ 7. Individual or Joint/Group Filing (check applicable line) |x| Form filed by One Reporting Person |_| Form filed by More than One Reporting Person ________________________________________________________________________________ ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship 2A. 3. Disposed of (D) Beneficially Form: 7. 2. Deemed Transaction (Instr. 3, 4 and 5) Owned Direct Nature of Trans- Execution Code ------------------------------- at the End (D) or Indirect 1. action Date, if (Instr. 8) (A) of Issuer's Indirect Beneficial Title of Security Date any ------------ or Fiscal Year (I) Ownership (Instr. 3) (mm/dd/yy) (mm/dd/yy) Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 962 D Self - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 660 I Wife - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* If the form is filed by more than one reporting person, see instruction 4(b)(v). FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
10. 9. Owner- Number ship 2. of of Conver- 5. 7. Deriv- Deriv- 11. sion Number of Title and Amount ative ative Nature or Derivative 6. of Underlying 8. Secur- Secur- of Exer- 3A. 4. Securities Date Securities Price ities ity: In- cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene- 1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Owned In- ficial Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- at End direct Owner- Derivative ative Date any 8) 4 and 5) Date Expira- Number ity of Year (I) ship Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity yy) yy) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: /S/ Gordon Charles Johnson 02/05/2003 - --------------------------------------------- ----------------------- **Signature of Reporting Person Date ** Intentional misstatements 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 provided is insufficient, see Instruction 6 for procedure. -----END PRIVACY-ENHANCED MESSAGE-----