-----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, Cz443ZBImPDGj5zwEs0HiJ1TMNtfPudeT5WwMXaMVgyYJ+74pzBlwfg/bqsM25WJ tASYF2ys2skT4R9wgnLenQ== 0000700565-02-000034.txt : 20021101 0000700565-02-000034.hdr.sgml : 20021101 20021101133535 ACCESSION NUMBER: 0000700565-02-000034 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20021101 FILED AS OF DATE: 20021101 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: FIRST MID ILLINOIS BANCSHARES INC CENTRAL INDEX KEY: 0000700565 STANDARD INDUSTRIAL CLASSIFICATION: STATE COMMERCIAL BANKS [6022] IRS NUMBER: 371103704 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-13368 FILM NUMBER: 02806419 BUSINESS ADDRESS: STREET 1: 1515 CHARLESTON AVE STREET 2: PO BOX 499 CITY: MATTOON STATE: IL ZIP: 61938 BUSINESS PHONE: 2172347454 MAIL ADDRESS: STREET 1: 1515 CHARLESTON AVENUE STREET 2: PO BOX 499 CITY: MATTOON STATE: IL ZIP: 61938 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: MELVIN GARY W CENTRAL INDEX KEY: 0001185506 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: 1515 CHARLESTON AVE CITY: MATTOON STATE: IL ZIP: 61938 BUSINESS PHONE: 2172580484 MAIL ADDRESS: STREET 1: 27 S COUNTRY CLUB ROAD CITY: MATTOON STATE: IL ZIP: 61938 4 1 form-4_melvin110102.txt GARY W MELVIN 11/01/02 ------------------------------ OMB APPROVAL ------------------------------ OMB Number: 3235-0287 Expires: January 31, 2005 Estimated average burden hours per response.........0.5 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 4 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 this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). (Print of Type Responses) ________________________________________________________________________________ 1. Name and Address of Reporting Person* Melvin Gary W - -------------------------------------------------------------------------------- (Last) (First) (Middle) RR #1, Box 226 - -------------------------------------------------------------------------------- (Street) Sullivan IL 61951 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol First MId-Illinois Bancshares, Inc. (FMBH.OB) ________________________________________________________________________________ 3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary) ________________________________________________________________________________ 4. Statement for Month/Day/Year November 1, 2002 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Day/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. Amount of 6. 4. Securities Owner- Securities Acquired (A) or Beneficially ship 2A. 3. Disposed of (D) Owned Form: 7. 2. Deemed Transaction (Instr. 3, 4 and 5) Following Direct Nature of Trans- Execution Code ------------------------------- Reported (D) or Indirect 1. action Date, if (Instr. 8) (A) Transaction(s) Indirect Beneficial Title of Security Date any ------------ or (Instr. 3 & (I) Ownership (Instr. 3) (mm/dd/yy) (mm/dd/yy) Code V Amount (D) Price Instr.4) (Instr.4) (Instr.4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 97,372.000 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 08/13/02 P 182.5868 A $26.31 13,961.6568 I Def Comp - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
FORM 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. Number 10. of Owner- deriv- ship ative Form 2. Secur- of Conver- 5. 7. ities Deriv- 11. sion Number of Title and Amount Bene- ative Nature or Derivative 6. of Underlying 8. ficially Secur- of Exer- 3A. 4. Securities Date Securities Price Owned ity: In- cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Follow- Direct direct Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ing (D) or Bene- 1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Reported In- ficial Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- Trans- direct Owner- Derivative ative Date any 8) 4 and 5) Date Expira- Number ity action(s) (I) ship Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity yy) yy) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 4,750 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: /s/ William S Rowland, Pursuant to a Power of Attorney filed contemporaneously herewith 11/01/02 - --------------------------------------------- ----------------------- **Signature of Reporting Person Date Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. * If the form is filed by more than one reporting person, see Instruction 4(b)(v). ** 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 is insufficient, see Instruction 6 for procedure. Page 2 EX-24 2 powerofatt_melvin.txt GARY W MELVIN 11/01/02 1 POWER OF ATTORNEY Know all by these presents, that the undersigned hereby constitutes and appoints each of William S. Rowland and Michael L. Taylor, signing singly, the undersigned's true and lawful attorney-in-fact to: (1) execute for and on behalf of the undersigned, in the undersigned's capacity as a beneficial owner of more than 10 percent of any class of equity security registered pursuant to Section 12 of the Securities Exchange Act of 1934, as amended (the "Act"), of and/or an officer and/or director of First Mid-Illinois Bancshares, Inc. (the "Company"), Forms ID, 3, 4, and 5 in accordance with Section 16(a) of the Act and the rules thereunder; (2) do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Form ID, 3, 4, or 5, complete and execute any amendment or amendments thereto, and timely file such form with the United States Securities and Exchange Commission and any stock exchange or similar authority; and (3) take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact's discretion. The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Act. This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms ID, 3, 4, and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 27th day of August, 2002. /s/ Gary W Melvin ---------------------------- Print Name:Gary W Melvin -----END PRIVACY-ENHANCED MESSAGE-----