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