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) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Stock Option (right to buy)
|
(1)
|
07/14/2024 |
Common Stock
|
50,000
|
$
2.69
|
D
|
|
Stock Option (right to buy)
|
(2)
|
03/11/2025 |
Common Stock
|
25,000
|
$
2.6
|
D
|
|
Stock Option (right to buy)
|
(3)
|
08/16/2026 |
Common Stock
|
40,000
|
$
2.76
|
D
|
|
* |
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) |
The option, representing the right to purchase a total of 50,000 shares of InfuSystem Holdings, Inc. common stock, vests in thirty-six monthly installments beginning August 14, 2014. |
(2) |
The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests in forty-eight monthly installments beginning April 11, 2015. |
(3) |
The option, representing the right to purchase a total of 40,000 shares of InfuSystem Holdings, Inc. common stock, vests in thirty-six monthly installments beginning Sept. 16, 2016. |