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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 | ||||||||
Stock Option (Right to Buy) | $ 2.39 | 10/15/2018 | M | 25,000 | 01/18/2018(2) | 10/19/2018(3) | Common Stock | 25,000 | $ 0 | 0 | D | ||||
Stock Option (Right to Buy) | $ 1.98 | 10/15/2018 | M | 20,833 | 07/19/2018(4) | 10/19/2018(3) | Common Stock | 20,833 | $ 0 | 0 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
DREYER DAVID C C/O INFUSYSTEM HOLDINGS, INC. 31700 RESEARCH PARK DRIVE MADISON HEIGHTS, MI 48071 |
X |
/s/ David C. Dreyer | 10/17/2018 | |
**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) | Reflects the number of shares surrendered in connection with the cashless exercise and tax withholding obligations for the exercised option. |
(2) | The option, representing the right to purchase a total of 25,000 shares, became exercisable in twelve equal monthly installments following the January 18, 2017 date of grant. |
(3) | The reporting person ceased to be a Director of the Company on July 19, 2018. The option expires three months after the date Optionee ceased to be a Director of the Company. |
(4) | The option, representing the right to purchase a total of 20,833 shares, became exercisable in ten equal monthly installments following the September 17, 2017 date of grant. All vesting ceased upon termination of the reporting person's service as a Director of the Company on July 19, 2018. |