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+--------+ U.S.
| FORM 5 | SECURITIES AND EXCHANGE COMMISSION
+--------+ Washington, D.C. 20549
[_] Check box if
no longer subject ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
to Section 16.
Form 4 or Form 5 Filed pursuant to Section 16(a) of the Securities
obligations may Exchange Act of 1934, Section 17(a) of the
continue. See Public Utility Holding Company Act of 1935 or
Instruction 1(b). Section 30(1) of the Investment Company Act of 1940
[_] Form 3 Holdings Reported
[_] Form 4 Transactions Reported
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1. Name and Address of Reporting Person
Bosma Roger
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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)
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) 151-32-8117
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4. Statement for Month/Year 12/31/00
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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)
[X] Director [X] Officer [_] 10% Owner [_] Other
(Title Below) (Specify Below)
0.05%
President
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Table 1--Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1. Title of Security 2. Transaction 3. Transaction 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature
(Instr. 3) Date Code or Disposed of (D) Securities Form: of Indirect
(Month/Day/ (Instr. 8) (Instr. 3, 4, and 5) Beneficially Direct Beneficial
Year) Owned at (D) or Ownership
End of Indirect (Instr. 4)
Lakeland Bancorp, Inc. Issuer's (I)
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(A) or Fiscal Year (Instr. 4)
Amount (D) Price (Instr. 3 & 4)
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Common 11/15/00 S/D 100 A 2100 D *1
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Common 02/15/00 DRP 24 A $12.5000
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Common 05/15/00 DRP 28 A $11.1190
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Common 07/03/00 VP 126 A $11.8125
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Common 08/15/00 DRP 26 A $11.7144
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Common 10/02/00 VP 134 A $11.2028
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Common 11/15/00 S/D 17 A
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Common 11/15/00 DRP 32 A $10.9258
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11/15/00 S/D 200 A 4587 1 2
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Reminder: Report on a seperate line for each class of securities beneficially
owned directly or indirectly.
FORM 5 (continued) Table 11 - Derivative Securities Acquired, Disposed of,
or Beneficially Owned (e.g., puts, calls, warrants,
options, convertible securities)
R Bosma
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1. Title of Derivative 2. Conversion 3. Transaction 4. Transaction 5. Number of Derivative
Security (Instr. 3) or Exercise Date Code Securities
Price of (Month/ (Instr. 8) Acquired (A) or
Derivative Day/Year) Disposed (D)
Security (Instr. 3, 4, & 5)
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(A) (D)
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Stock Option
Right to purchase 9.38 2/9/00 A 20,000 ---
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*1 Stock Option was granted pursuant to Company's 2000 Equity Compensation program and vests in 25% annual installments
beginning one year after the grant date
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6. Date Exercisable 7. Title and Amount of 8. Price 9. Number 10. Ownership 11. Nature
and Expiration Underlying Securities of of Derivative of Derivative of Indirect
Date (Instr. 3 & 4) Derivative Securities Security: Beneficial
(Month/Day/ Security Beneficially Direct Ownership
Year) (Instr. 5) Owned (D) or (Instr. 4)
at End Indirect (1)
of Year (Instr. 4)
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Date Expiration Amount or
Exercisable Date Title Number of
Shares
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*1 2/8/10 Common 20,000 --- 20,000 D ---
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Explanation of Responses:
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CODES
1. In IRA a/c for Roger Bosma
2. Held jointly by Roger and Holly Bosma, wife of Roger Bosma
DRP - Dividend Reinvestment Plan
S/D - Stock Dividend
VP - Voluntary Purchase
/s/ [ILLEGIBLE]^^ 1/18/01
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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.