UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Call Equivalent Position | Â (2) | Â (2) | Common Stock | 40,292 | $ (2) | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
GRISSOM STEVEN L 121 SOUTH 17TH STREET MATTOON, IL 61938-3987 |
 |  |  Treasurer and Secretary |  |
James N. Pepin, Power of Attorney | 07/22/2005 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | Shares acquired pursuant to a reorganization as described in the issuer's registration statement on Form S-1 (Registration No. 333-121086). Shares were originally awarded under a restricted share plan pursuant to which a cumulative 50% of the shares are vested on the day prior to the reorganization. The remaining 50% will vest in three equal installments on December 31, 2005, 2006 and 2007. |
(2) | Represents a pecuniary interest in shares held by Central Illinois Telephone LLC which will be distributed in-kind and pro-rata to the reporting person's interest in Central Illinois Telephone LLC promptly after the closing of, or expiration of, the over-allotment option of the issuer's initial public offering. Reporting person has no beneficial interest in the shares held by Central Illinois Telephone LLC. |