- Annual Statement of Changes in Beneficial Ownership (5)
February 17 2009 - 11:59AM
Edgar (US Regulatory)
FORM 5
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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Form 3 Holdings Reported
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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
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1. Name and Address of Reporting Person
*
JORGENSEN DWAIN C
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2. Issuer Name
and
Ticker or Trading Symbol
HMN FINANCIAL INC [HMNF]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
_____ 10% Owner
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X
__ Officer (give title below)
_____ Other (specify below)
SENIOR VICE PRESIDENT
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(Last)
(First)
(Middle)
1016 CIVIC CENTER DR NW
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2008
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(Street)
ROCHESTER, MN 55901
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
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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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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Amount
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(A) or (D)
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Price
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Common Stock
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37047
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D
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Common Stock
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2150
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I
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Spouse Marcia Jorgensen
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Common Stock
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16481
(1)
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I
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ESOP Allocation
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Common Stock
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5200
(2)
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I
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401(k)
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Optoin to Buy
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$16.13
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4/16/2010
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4/15/2012
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Common Stock
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102
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102
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D
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Option to Buy
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$16.13
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4/16/2011
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4/15/2012
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Common Stock
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6199
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6301
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D
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Option to Buy
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$16.13
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1/1/2012
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4/15/2012
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Common Stock
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6199
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12500
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D
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Option to Buy
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$27.66
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3/3/2005
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3/3/2014
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Common Stock
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1194
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1194
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D
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Option to Buy
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$27.66
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3/3/2006
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3/3/2014
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Common Stock
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1193
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2387
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D
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Option to Buy
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$27.66
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3/3/2007
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3/3/2014
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Common Stock
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1193
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3580
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D
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Explanation of Responses:
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(
1)
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Number of shares for ESOP holding includes allocation for the year ended Dec 31, 2008.
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(
2)
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Number of shares shown for 401(k) holdings reflects automatic purchases within the plan during 2008.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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JORGENSEN DWAIN C
1016 CIVIC CENTER DR NW
ROCHESTER, MN 55901
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SENIOR VICE PRESIDENT
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Signatures
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Jon Eberle for Dwain Jorgensen by Power of Attorney
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2/17/2009
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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