FORM 5
UNITES STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Files pursuant to Section 16(a) of the Securities Exchange Act
of 1934, Section 17(a) of the Public Utility Reported Holding
Company Act of 1935 or Section 30(f) of the Investment Company Act of 1940
[] Check here if no longer subject to
Section 16 Form 4 or Form 5 obli-
gations may continue. See instruc-
tion 1(b)
[] Form 3 Holdings
[] Form 4 Transactions Reported
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) to
Issuer
Emclaire Financial Corp. (EMCF) (Check all applicable)
[X] Director [ ] 10% Owner
[ ] Officer (give title [ ] Other (specify
below) below)
Mason John B.
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(Last) (First) (Middle) 3. I.R.S. Identification 4. Statement for 7. Individual or
Number of Reporting Month/Year Joint/Group Filing
Person, if an entity (Check Applicable
(Voluntary) 12/02 Line)
104 Mason Lane 5. If Amendment, [X] Form filed by
------------------------------------------------------- Date of Original One Reporting Person
(Street) (Month/Year)
[ ] Form filed by More
than One Reporting
Person
Knox PA 16232
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(City) (State) (Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security 2.Transaction Date 2A. Deemed Execution 3. Transaction 4. Securities 5. Amount of 6. Owner- 7. Nature
(Instr. 3) (Month/Day/Year) Date, if any Code (Instr. Acquired Securities ship Form: of
(Month 8) (A) or Beneficially Direct Indirect
/Day/Year) Disposed Owned at (D) or Benefi-
of (D) End of Indirect cial
(Instr. 3, Issuer's (I) Owner-
4, and 5) Fiscal (Instr. ship
Year 4) (Instr.
(Instr. 3 4)
& 4)
Amount (A) or (D) Price
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Common Stock J 5,014.405(1) D
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Common Stock J 531.120(2) I Custodian
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(1) Includes 199.405 shares acquired in 2002 under Emclaire Financial Corp.'s dividend reinvestment plan.
(2) Includes 21.120 shares acquired in 2002 under Emclaire Financial Corp's dividend reinvestment plan.
* If the form is filed by more than one reporting person, see instruction 4(b)(v). Potential persons who are to 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.
(over)
SEC 2270
FORM 5 (continue)
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 2. 3. 3A. 4. 5. Number of 6. Date 7. Title 8. Price 9. Number 10. 11. Nature
Derivative Conversion Transaction Deemed Transac- Derivative Exercisable and of of Owner- of
Security or Date Execution tion Securities and Amount Deriv- Deriv- ship Indirect
(Instr. 3) Exercise (Month/ Date if Code Acquired (A) Expiration of ative ative Form Benefi-
Price Day/Year) any (Instr. or Date Under- Security Securities of cial
of (Month/ 8) Disposed (Month lying (Instr. 5) Benefi- Deriv- Owner-
Derivative Day/Year) of Date(D) /Day Securi cially ative ship
Security (Instr. 3, /Year) -ties Owned Security: (Instr.
4, and 5) (Instr. End Direct 4)
3 of (D)
and 4) Year or
(Instr. Indirect
4) (I)
(A) (D) Date Expir- Title Amount or (Instr.4)
Exercis- ation Number of
able Date Shares
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Explanation of Responses:
/s/ John B. Mason 02/07/03
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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 is insufficient, see Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained
in this form are not required to respond unless form displays a currently valid
OMB number.