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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 5
ANNUAL 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 box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
|_| Form 3 Holdings Reported
|_| Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
Diepholz Kenneth R.
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(Last) (First) (Middle)
1421 Cross Creek
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(Street)
Mattoon IL 61938
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
First Mid-Illinois Bancshares, Inc. (FMBH.OB)
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3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary)
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4. Statement for Month/Year
November, 2002
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5. If Amendment, Date of Original (Month/Year)
December, 2001
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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
________________________________________________________________________________
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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5. 6.
4. Amount of Owner-
Securities Acquired (A) or Securities ship
2A. 3. Disposed of (D) Beneficially Form: 7.
2. Deemed Transaction (Instr. 3, 4 and 5) Owned Direct Nature of
Trans- Execution Code ------------------------------- at the End (D) or Indirect
1. action Date, if (Instr. 8) (A) of Issuer's Indirect Beneficial
Title of Security Date any ------------ or Fiscal Year (I) Ownership
(Instr. 3) (mm/dd/yy) (mm/dd/yy) Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4)
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Common Stock 11/16/01 J(2) 12,096.00 A 36,289.00 (1) D
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Common Stock 11/21/01 J(2) 3,384.00 A 10,152.00 (1) I By IRA
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* If the form is filed by more than one reporting person, see instruction
4(b)(v).
FORM 5 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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10.
9. Owner-
Number ship
2. of of
Conver- 5. 7. Deriv- Deriv- 11.
sion Number of Title and Amount ative ative Nature
or Derivative 6. of Underlying 8. Secur- Secur- of
Exer- 3A. 4. Securities Date Securities Price ities ity: In-
cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct
Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene-
1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Owned In- ficial
Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- at End direct Owner-
Derivative ative Date any 8) 4 and 5) Date Expira- Number ity of Year (I) ship
Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity yy) yy) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Common Stock 11/16/01 J(2) 1,250 Common
Stock 3,750 D
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Common Stock $24.00 12/18/01 A 1,000 Immed 12/18/11 Common
Stock 1,000 4,750 D
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Explanation of Responses:
(1) The reporting person filed a Form 5 for December 2001 that mistakenly
reported acquisitions in the 2000 and 2001 calendar years of Common Stock
totaling 122.5326 shares with respect to Deferred Compensation that belong
to his adult son Kenneth R. Diepholz Jr. This Form 5 as amended excludes all
such acquistions of the foregoing shares. This Form 5 as amended applies to
all subsequent reports of the reporting person of acquisitions of Common
Stock with respect to Defered Compensation, including a Form 4 dated August
2002 and a Form 4 dated November 1, 2002. The foregoing Form 4s are amended
to exclude all such acquisitions of Common Stock with respect to Deferred
Compensation.
(2) Shares acquired through Company's three-for-two stock split in the form of a
stock dividend.
/s/ William S Rowland, Pursuant to a Power
of Attorney filed on November 1, 2002 11/06/02
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**Signature of Reporting Person Date
** 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 provided is insufficient, see Instruction 6 for procedure.