Annual Statement of Changes in Beneficial Ownership (5)
February 14 2017 - 2:15PM
Edgar (US Regulatory)
FORM 5
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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Form 3 Holdings Reported
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
MURPHY CHRISTOPHER J III
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2. Issuer Name
and
Ticker or Trading Symbol
1ST SOURCE CORP [SRCE]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chairman, CEO
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(Last)
(First)
(Middle)
PO BOX 1602
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2016
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(Street)
SOUTH BEND, IN 46634
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Amount
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(A) or (D)
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Price
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Common Stock
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530229
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D
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Common Stock
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1/4/2016
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G
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825
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D
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$0
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2604780
(1)
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I
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By Spouse
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Common Stock
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11/16/2016
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G
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5000
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D
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$0
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2599780
(1)
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I
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By Spouse
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Common Stock
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52521
(2)
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I
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By 401(k)
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Common Stock
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125893
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I
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By Corporation
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Common Stock
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438131
(3)
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I
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By ERCO II Partnership
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Common Stock
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282119
(3)
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I
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By ERCO III Partnership
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Common Stock
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214770
(3)
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I
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By Ltd. Partnership
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Common Stock
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584600
(4)
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I
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By LLC
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(
1)
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Mr. Murphy disclaims beneficial ownership of these securities, and this report shall not be deemed an admission that Mr. Murphy is the beneficial owner of the securities for purposes of Section 16 or for any other purpose.
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(
2)
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Between January 1, 2016 and December 31, 2016, Mr. Murphy acquired a total of 1,242 shares of 1st Source Corporation common stock under the 401(k) Plan. The information in this report is based on a plan statement dated as of December 31, 2016.
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(
3)
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Mr. Murphy disclaims beneficial ownership of those shares held by the partnership exceeding his pecuniary interest, and this report shall not be deemed an admission that Mr. Murphy is the beneficial owner of such excess shares for purposes of Section 16 or for any other purpose.
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(
4)
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Mr. Murphy's spouse is a voting member, and Mr. Murphy is a non-voting member, of the LLC. Mr. Murphy disclaims beneficial ownership of those shares held by the LLC exceeding his pecuniary interest, and this report shall not be deemed an admission that Mr. Murphy is the beneficial owner of such excess shares for purposes of Section 16 or for any other purpose.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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MURPHY CHRISTOPHER J III
PO BOX 1602
SOUTH BEND, IN 46634
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X
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X
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Chairman, CEO
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Signatures
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/s/ John B. Griffith, Attorney-in-Fact
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2/14/2017
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number.
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