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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 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. | |||
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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Sansone Christopher R. C/O INFUSYSTEM HOLDINGS, INC. 31700 RESEARCH PARK DRIVE MADISON HEIGHTS, MI 48071 |
X |
/s/Trent N. Smith, Attorney-in-Fact for Christopher R. Sansone | 11/28/2017 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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 reported securities are directly owned by Sansone Partners, L.P. |
(2) | The reported securities are directly owned by Sansone Partners (QP), L.P. |
(3) | The reported securities are directly owned by (i) Sansone Partners, L.P., a Delaware limited partnership (the "3c1 Partnership"), and (ii) Sansone Partners (QP), L.P., a Delaware limited partnership (the "3c7 Partnership," and together with the 3c1 Partnership, the "Partnerships"), and may be deemed to be indirectly owned by Sansone Advisors, LLC, a Delaware limited liability company, as the investment manager of Partnerships (the "Investment Manager"), and by Sansone Capital Management, LLC, a Delaware limited liability company, as the general partner of the Partnerships (the "General Partner"). The reported securities may also be deemed to be indirectly beneficially owned by Christopher Sansone as the managing member of the Investment Manager and the General Partner. The Reporting Persons disclaim beneficial ownership of the reported securities except to the extent of his or its pecuniary interest therein. |