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FORM 5 U.S. SECURITIES AND EXCHANGE COMMISSION OMB APPROVAL
------ Washington, D.C. 20549 =========================
OMB Number: 3235-0362
ANNUAL STATEMENT OF CHANGES IN Expires: February 1, 1994
BENEFICIAL OWNERSHIP Estimated average burden
hours per response... 1.0
[_] 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
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(f) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
TICE, CHARLES
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(Last) (First) (Middle)
C/O Lakeland Bancorp, Inc.
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(Street)
Oak Ridge, NJ 07438
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(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol:
LAKELAND BANCORP, INC.
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3. IRS or Social Security Number of Reporting Person (Voluntary):
138-28-5885
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4. Statement for Month/Year:
12/31/00
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5. If Amendment, Date of Original (Month/Year):
4/00
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6. Relationship of Reporting Person to Issuer (Check all applicable):
_X__ Director ___ 10% Owner __ Officer _X__ Other
(Title Below) (Specify Below)
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TABLE 1 - NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF,
OR BENEFICIALLY OWNED
5. Amount of
4. Securities Acquired (A) Securities Bene- 7. Nature of
2. Trans- 3. Trans- or Disposed of (D) (Instr. ficially Owned at 6. Ownership Indirect
Title of action Date action 3, 4, and 5) End of Issuer's Form: Direct Beneficial
Security (Month/Day/ Code ------------------------------ Fiscal Year (D) or Indirect Ownership
(Instr. 3) Year) (Instr. 8) Amount (A) or (D) Price (Instr. 3 and 4) (I) (Instr. 4) (Instr. 4)
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LAKELAND
BANCORP, INC.
Common
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Common 5/15/00 DRP 122 A $11.119 D *1
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8/15/00 DRP 116 A 11.714 D *1
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11/15/00 DRP 134 A 10.925 D *1
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11/15/00 DRP 917 A 19410 D *1
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5/15/00 DRP 20 A 11.119 I *2
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8/15/00 DRP 19 A 10.536 I *2
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11/15/00 DRP 22 A 10.9258 I *2
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11/15/00 S/D 152 A 3213 I *2
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11/15/00 S/D 295 A 10.9258 6195 I *3
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Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
FORM 5 (Continued)
Table II - Derivative Securities Acquired, Disposed of,
or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exercisable and 7. Title and Amount of
Security (Instr. 3) sion or action Date action Code Derivative Sec- Expiration Date Underlying Securities
Exercise (Month/ (Instr. 8) urities Acquired (Month/Day/Year) (Instr. 3 and 4)
Price of Day/Year) (A) or Disposed
Derivative (D) (Instr. 3, 4
Security and 5)
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Date Expiration Amount or
(A) (D) Exercisable Date Title Number of
Shares
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Stock Option
Right to Purchase 9.38 2/9/00 A 25,000 __ * 2/8/10 Common 25,000
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* Stock Option was granted pursuant to Company's 2000 Equity Compensation program and vests in 20% annual installments
beginning on the grant date
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8. Price of 9. Number of Derivative 10. Ownership of 11. Nature of
Derivative Securities Beneficially Derivative Sec- Indirect Bene-
Security Owned at End of Year urity: Direct (D) ficial Ownership
(Instr. 5) (Instr. 4) or Indirect (I) (Instr. 4)
(Instr. 4)
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Stock Option
Right to Purchase -- 25,000 D --
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Explanation of Responses:
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*1 Solely owned by Charles Tice
*2 Owned by Charles Tice & Mark Cummins, co-trustees for Mark Cummins
*3 Owned by Charles Tice & Mark Cummins, co-trustees for Mark Cummins
Code, DRP - Dividend Reinvestment Plan
S/D - Stock Dividend
/s/
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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. 7811(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.