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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(1) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
Nicholson Robert B
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(Last) (First) (Middle)
c/o Lakeland Bancorp, Inc.
250 Oak Ridge Road
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(Street)
Oak Ridge New Jersey 07438
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(City) (State) (Zip)
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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):
155-20-8347
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4. Statement for Month/Year:
12/31/00
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5. If Amendment, Date of Original (Month/Year):
Dec-99
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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)
2.36%
Vice Chairman
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TABLE 1 - NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF,
OR BENEFICIALLY OWNED
Title of 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of
Security action Date action or Disposed of (D) (Instr. Securities Bene- Form: Direct Indirect
(Instr. 3) (Month/Day/ Code 3, 4, and 5) ficially Owned at (D) or Indirect Beneficial
Year) (Instr. 8) End of Issuer's (I) (Instr. 4) Ownership
Lakeland ------------------------------ Fiscal Year (Instr. 4)
Bancorp, Inc. Amount (A) or (D) Price (Instr. 3 & 4)
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Common 11/15/00 S/D 10262 A $10.5360 215516 D *1
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Common 11/15/00 S/D 4692 A $10.5360 98536 I *2
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Common 02/25/00 S 9124 D $10.0000 I *3
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Common 03/01/00 S 5282 D $9.9375 0 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 & 4)
Price of Day/Year) (A) or Disposed
Derivative (D) (Instr. 3, 4
Security & 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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1. Title of Derivative 8. Price of 9. Number of Derivative 10. Ownership of 11. Nature of
Security (Instr. 3) Derivative Securities Beneficially Derivative Sec- Indirect Bene-
Securities 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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*Stock Option was granted pursuant to Company's 2000 Equity Compensation Program
and vests in 20% annual installments beginning
on grant date.
Explanation of Responses:
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*1 - Solely owned by R. Nicholson
*2 - Solely owned by Shirley Nicholson, wife of Robert B. Nicholson
*3 - Owned by Eastern Propane - Employees Profit & Sharing, a company which was
owned by Robert B. Nicholson
/s/ Robert B Nicholson 1/26/00
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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.