UNITED STATES 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(h) 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*
Blum John Robert Halsey
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(Last) (First) (Middle)
406 Sharon Road
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(Street)
Lakeville CT 06039
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Salisbury Bancorp, Inc. (SAL)
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3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary)
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4. Statement for Month/Year
December 2002
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|x| Director |_| 10% Owner
|_| Officer (give title below) |_| Other (specify below)
President & CEO
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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-
Securities Acquired (A) or Securities ship
2A. 3. Disposed of (D) Beneficially Form: 7.
2. Deemed Transaction (Instr. 3, 4 and 5) Owned Direct Nature of
Trans- Execution Code ------------------------------- at the End (D) or Indirect
1. action Date, if (Instr. 8) (A) of Issuer's Indirect Beneficial
Title of Security Date any ------------ or Fiscal Year (I) Ownership
(Instr. 3) (mm/dd/yy) (mm/dd/yy) Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4)
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Common Stock 4,176 D Self IRA
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Common Stock 9,060 D Self Trust
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Common Stock 2,100 I Wife
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Common Stock 120 D Self
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* If the form is filed by more than one reporting person, see instruction
4(b)(v).
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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10.
9. Owner-
Number ship
2. of of
Conver- 5. 7. Deriv- Deriv- 11.
sion Number of Title and Amount ative ative Nature
or Derivative 6. of Underlying 8. Secur- Secur- of
Exer- 3A. 4. Securities Date Securities Price ities ity: In-
cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct
Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene-
1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Owned In- ficial
Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- at End direct Owner-
Derivative ative Date any 8) 4 and 5) Date Expira- Number ity of Year (I) ship
Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity yy) yy) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Explanation of Responses:
/s/John Robert Halsey Blum February 5, 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.