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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) | $ 8.58 (2) | 05/17/2022 | A | 18,328 | (3) | 05/17/2032 | Common Stock | 18,328.00 | $ 0 | 18,328 | D | ||||
Restricted Stock Units | (4) | 05/17/2022 | A | 12,500 | (5) | (5) | Common Stock | 12,500.00 | $ 0 | 12,500 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
RUIZ THOMAS MARK C/O INFUSYSTEM HOLDINGS, INC. 3851 WEST HAMLIN ROAD ROCHESTER HILLS, MI 48309 |
Chief Commercial Officer |
/s/ Kevin Whitman, Attorney-in-Fact for Thomas Ruiz | 05/17/2022 | |
**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) | This total includes an additional 732 shares acquired recently through the Company's Employee Stock Purchase Plan |
(2) | The stock option was issued with an exercise price equal to the Fair Value as defined by the 2021 Equity Plan, which is computed as the closing price of the Company's common stock reported on the NYSE American LLC on the date of grant. |
(3) | The option, representing the right to purchase a total of 18,328 shares of InfuSystem Holdings, Inc. common stock, vests in three equal annual installments beginning May 17, 2023. |
(4) | Restricted stock units convert into common stock on a one-for-one basis. |
(5) | These restricted stock units will cliff vest on May 17, 2025. |