-----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, LNgW7DTZMj8DrUrhnxwzHPlEooU+12MpLu1xXej7XLDsJ8pxLwcstafS9AScRtDW c2sAZcSgl0dccnOfcojoXw== 0000702325-04-000184.txt : 20041213 0000702325-04-000184.hdr.sgml : 20041213 20041213181309 ACCESSION NUMBER: 0000702325-04-000184 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20041207 FILED AS OF DATE: 20041213 DATE AS OF CHANGE: 20041213 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: KENT S BELASCO CENTRAL INDEX KEY: 0001279182 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-10967 FILM NUMBER: 041199814 BUSINESS ADDRESS: STREET 1: FIRST MIDWEST BANCORP INC STREET 2: 300 PARK BLVD SUITE 400 CITY: ITASCA STATE: IL ZIP: 60143 BUSINESS PHONE: 6308757450 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: FIRST MIDWEST BANCORP INC CENTRAL INDEX KEY: 0000702325 STANDARD INDUSTRIAL CLASSIFICATION: NATIONAL COMMERCIAL BANKS [6021] IRS NUMBER: 363161078 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 300 PARK BLVD SUITE 405 STREET 2: P O BOX 459 CITY: ITASCA STATE: IL ZIP: 60143-0459 BUSINESS PHONE: 7088757450 MAIL ADDRESS: STREET 1: 300 PARK BLVD SUITE 405 STREET 2: P O BOOX 459 CITY: ITASCA STATE: IL ZIP: 60143-0459 4 1 bel263.xml X0202 4 2004-12-07 0 0000702325 FIRST MIDWEST BANCORP INC FMBI 0001279182 KENT S BELASCO 300 PARK BOULEVARD, SUITE 400 ITASCA IL 60143 0 1 0 0 EVP, Chief Information Officer Phantom Stock under NQ Retirement Plan 2004-12-07 4 A 0 5 36.4500 A Common Stock 5 1001 D Shares of phantom stock in the NQ Retirement Plan have a 1-for-1 conversion ratio. Between November 27, 2004 and December 13, 2004 the reporting person acquired 5 shares of First Midwest common stock under the First Midwest Bancorp, Inc Non-Qualified Retirement Plan. The information in this report is based on a plan statement dated December 10, 2004. Shares of phantom stock in the NQ Retirement Plan are exercisable immediately. Shares of phantom stock in the NQ Retirement Plan are payable in cash following the termination of the reporting person's employment with First Midwest Bancorp, Inc. By: Andrea L. Stangl, Attorney-in-fact for 2004-12-13 -----END PRIVACY-ENHANCED MESSAGE-----