Annual Statement of Changes in Beneficial Ownership (5)
February 13 2018 - 5:05PM
Edgar (US Regulatory)
FORM 5
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
[ ]
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
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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 Carmen C
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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)
_____ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
1237 EAST JEFFERSON BOULEVARD
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2017
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(Street)
SOUTH BEND, IN 46617
(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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4/24/2017
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G
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513
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D
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$0
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129404
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D
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Common Stock
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4/24/2017
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G
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1987
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D
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$0
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127417
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D
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Common Stock
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11/21/2017
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G
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5000
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D
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$0
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122417
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D
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Common Stock
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12/27/2017
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G
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7995
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D
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$0
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114422
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D
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Common Stock
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4/24/2017
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G
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2500
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D
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$0
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1641163
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I
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By Spouse
(1)
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Common Stock
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11/21/2017
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G
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5000
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D
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$0
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1636163
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I
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By Spouse
(1)
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Common Stock
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12/27/2017
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G
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2665
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D
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$0
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1634495
(2)
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I
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By Spouse
(1)
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Common Stock
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584600
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I
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By LLC
(3)
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Common Stock
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283897
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I
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By Trust
(4)
(5)
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Common Stock
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646582
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I
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By Trust
(5)
(6)
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Common Stock
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17246
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I
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By Trust
(5)
(7)
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Common Stock
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43132
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I
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By Trust
(5)
(8)
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Common Stock
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41640
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I
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By Trust
(5)
(9)
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Common Stock
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115684
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I
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By Trust
(5)
(10)
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Common Stock
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708289
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I
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By Trust
(5)
(11)
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Common Stock
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147255
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I
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By Trust
(5)
(12)
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Common Stock
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229930
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I
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By Trust
(5)
(13)
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Common Stock
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1598
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I
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By Trust
(5)
(14)
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Common Stock
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6228
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I
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By Trust
(5)
(15)
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Common Stock
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228382
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I
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By Trust
(5)
(16)
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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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Includes 520,064 shares of common stock held directly by Mr. Murphy, 53,518 shares of common stock held indirectly by Mr. Murphy under the 1st Source Corporation 401(k) Plan, 125,893 shares of common stock held indirectly by Mr. Murphy through a corporation and 935,020 shares of common stock held indirectly by Mr. Murphy through three limited partnerships. Mrs. Murphy disclaims beneficial ownership of these shares of common stock, and this report on Form 3 shall not be deemed an admission that Mrs. Murphy is the beneficial owner of these shares of common stock for purposes of Section 16 or for any other purpose.
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(2)
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Between January 1, 2017 and December 31, 2017, Mr. Murphy acquired a total of 997 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, 2017.
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(3)
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Mrs. Murphy is a voting member of the LLC. Mrs. Murphy disclaims beneficial ownership of those shares of common stock held by the LLC exceeding her pecuniary interest, and this report shall not be deemed an admission that Mrs. Murphy is the beneficial owner of such excess shares of common stock for purposes of Section 16 or for any other purpose.
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(4)
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Indirect through the 1957 E. L. Morris FBO Carmen C. Murphy Trust.
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(5)
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Mrs. Murphy has the power to direct the trustee with respect to the disposition of the reported shares of common stock. Mrs. Murphy disclaims beneficial ownership of these shares of common stock except to the extent of her pecuniary interest therein, and the inclusion of these shares of common stock in this report shall not be deemed an admission of beneficial ownership of all of the reported shares of common stock for purposes of Section 16 or for any other purpose.
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(6)
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Indirect through the 1959 E. L. Morris FBO Carmen C. Murphy Trust.
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(7)
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Indirect through the E. M. Raclin FBO Carmen C. Murphy Trust.
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(8)
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Indirect through a 1965 E. L. Morris FBO E. M. Raclin and Carmen C. Murphy Trust.
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(9)
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Indirect through a second 1965 E. L. Morris FBO E. M. Raclin and Carmen C. Murphy Trust.
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(10)
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Indirect through the Carmen C. Murphy Charitable Annuity Trust.
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(11)
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Indirect through the Ella Morris Trust FBO Carmen C. Murphy.
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(12)
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Indirect through the Ernestine M. Raclin Charitable Irrevocable Trust FBO Carmen C. Murphy.
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(13)
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Indirect through the 1960 Ernestine M. Raclin Irrevocable Trust FBO Carmen C. Murphy.
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(14)
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Indirect through the Ella Morris Charitable Trust FBO Carmen C. Murphy.
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(15)
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Indirect through the Ella Morris Irrevocable Charitable Living Trust FBO Carmen C. Murphy.
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(16)
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Indirect through the 1965 Ernestine M. Raclin Irrevocable Trust FBO Carmen C. Murphy.
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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 Carmen C
1237 EAST JEFFERSON BOULEVARD
SOUTH BEND, IN 46617
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X
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Signatures
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/s/ John B. Griffith, Attorney-in-Fact for Carmen C. Murphy (power of attorney previously filed)
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2/13/2018
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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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