0001415889-18-000884.txt : 20180606
0001415889-18-000884.hdr.sgml : 20180606
20180606125736
ACCESSION NUMBER: 0001415889-18-000884
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20180604
FILED AS OF DATE: 20180606
DATE AS OF CHANGE: 20180606
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: FOSS RICHARD A
CENTRAL INDEX KEY: 0001211685
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-34821
FILM NUMBER: 18883433
MAIL ADDRESS:
STREET 1: C/O JACKSONVILLE SAVINGS BANK
STREET 2: 1211 WEST MORTON AVE
CITY: JACKSONVILLE
STATE: IL
ZIP: 62650
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Jacksonville Bancorp, Inc.
CENTRAL INDEX KEY: 0001484949
STANDARD INDUSTRIAL CLASSIFICATION: SAVINGS INSTITUTION, FEDERALLY CHARTERED [6035]
IRS NUMBER: 000000000
STATE OF INCORPORATION: MD
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 1211 WEST MORTON AVENUE
CITY: JACKSONVILLE
STATE: IL
ZIP: 62650
BUSINESS PHONE: (217) 245-4111
MAIL ADDRESS:
STREET 1: 1211 WEST MORTON AVENUE
CITY: JACKSONVILLE
STATE: IL
ZIP: 62650
4
1
form4-06062018_090621.xml
X0306
4
2018-06-04
1
0001484949
Jacksonville Bancorp, Inc.
JXSB
0001211685
FOSS RICHARD A
C/O JACKSONVILLE BANCORP, INC.
1211 W. MORTON AVE.
JACKSONVILLE
IL
62650
true
true
false
false
PRESIDENT AND CEO
Common Stock
2017-12-31
5
A
0
245
32.02
A
5074
I
By ESOP
Common Stock
2018-05-17
5
G
0
1000
D
27453
D
Common Stock
2018-05-17
5
G
0
2600
D
24853
D
Common Stock
2018-06-04
4
D
0
24853
D
0
D
Common Stock
2018-06-04
4
D
0
5074
D
0
I
By ESOP
Common Stock
2018-06-04
4
D
0
40332
D
0
I
By 401k
Common Stock
2018-06-04
4
D
0
4156
D
0
I
By IRA
Common Stock
2018-06-04
4
D
0
45
D
0
I
By Spouse
Stock Option
15.65
2018-06-04
4
D
0
7200
D
2013-04-24
2022-04-24
Common Stock
7200
0
D
Gift of 250 shares to each of his 4 grandchildren.
Gift of 2,600 shares owned jointly with spouse to Schwab Charitable.
Each share of common stock was converted into and became exchangeable for the right to receive $33.70 in cash pursuant to an agreement and plan of merger between the Jacksonville Bancorp, Inc., CNB Bank Shares, Inc. and CNB Acquisition, Inc.
The stock option was cancelled in connection with the merger and the holder received a cash payment upon such cancellation in an amount equal to $129,960.00, the product of (i) the number of shares or Issuer common stock provided for by such option and (ii) $33.70 minus $15.65, the exercise price of the option.
/s/ Richard A. Foss
2018-06-05