U.S. 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(f) 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*
Hiebert Quinton L.
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(Last) (First) (Middle)
11748 SW Seventh
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(Street)
Yukon OK 73099
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Summit Life Corporation (SUMC)
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Year
December 31, 2002
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
Prinipal Accounting Officer
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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-
2A. Securities Acquired (A) or Securities ship
Deemed Disposed of (D) Beneficially Form: 7.
2. Execu- (Instr. 3, 4 and 5) Owned at End Direct Nature of
Trans- tion 3. ----------------------------- of Issuer's (D) or Indirect
1. action Date Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date if any Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4)
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Common Stock 1/31/02 -- L 500 A $ 650.00 375 I IRA
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Common Stock 4/30/02 -- L 200 A $1,000.00 5,675 D
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* If the form is filed by more than one Reporting Person, see Instruction
4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print or Type Responses) (Over)
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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9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 3A. 5. 7. ative Deriv- 11.
sion Deem- Number of Title and Amount Secur- ative Nature
or ed Derivative 6. of Underlying 8. ities Secur- of
Exer- Exe- Securities Date Securities Price Bene- ity: In-
cise 3. cution Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- Date 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action if, Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date any action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ (Month Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Explanation of Responses:
/s/ Quinton L. Hiebert March 20, 2003
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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.