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)
|
09/07/2018 |
09/06/2022 |
Common Stock
|
7,500
|
$
1.98
|
D
|
|
Stock Option (right to buy)
(2)
|
09/07/2018 |
09/06/2022 |
Common Stock
|
10,000
|
$
1.98
|
D
|
|
Stock Option (right to buy)
(3)
|
04/20/2019 |
04/19/2028 |
Common Stock
|
50,000
|
$
2.7
|
D
|
|
Stock Option (right to buy)
(4)
|
07/19/2019 |
07/18/2023 |
Common Stock
|
25,000
|
$
3.36
|
D
|
|
Stock Option (right to buy)
(5)
|
05/15/2020 |
05/14/2029 |
Common Stock
|
40,000
|
$
4.7
|
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 7,500 shares of InfuSystem Holdings, Inc. common stock, vests 33% per year on the anniversary starting September 7, 2018. |
(2) |
The option, representing the right to purchase a total of 10,000 shares of InfuSystem Holdings, Inc. common stock, vests 50% per year on the anniversary starting September 7, 2018. |
(3) |
The option, representing the right to purchase a total of 50,000 shares of InfuSystem Holdings, Inc. common stock, vests 33% per year on the anniversary starting April 20, 2019. |
(4) |
The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests 33% per year on the anniversary starting July 19, 2019. |
(5) |
The option, representing the right to purchase a total of 40,000 shares of InfuSystem Holdings, Inc. common stock, vests 33% per year on the anniversary starting May 15, 2020. |