SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP


Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
OMB APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response: 0.5
  
 Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
Chupa Addam
(Last) (First) (Middle)
C/O INFUSYSTEM HOLDINGS, INC.
3851 WEST HAMLIN ROAD
(Street)
ROCHESTER HILLS MI 48309
(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
InfuSystem Holdings, Inc [ INFU ] 		5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Executive VP and CIO
3. Date of Earliest Transaction (Month/Day/Year)
05/18/2023
4. If Amendment, Date of Original Filed (Month/Day/Year)
 6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Rule 10b5-1(c) Transaction Indication

  
 Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 05/20/2023 M(1) 2,500 A $0 19,481 D
Common Stock 05/20/2023 F(2) 1,015 D $9.12 18,466 D
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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 Securities Underlying Derivative Security (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: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Stock Options (right to buy) $9.18 05/18/2023 A 36,636 (3) 05/18/2033 Common Stock 36,636 $0 36,636 D
Restricted Stock Units (4) 05/18/2023 A 5,447 (5) 05/18/2026 Common Stock 5,447 $0 5,447 D
Restricted Stock Units (4) 05/20/2023 M 2,500 (6) (6) Common Stock 2,500 $0 0 D
Explanation of Responses:
1. Vesting of restricted stock award granted on May 20, 2020
2. Represents the withholding of the Issuer's common stock for the tax liability associated with the vesting and settlement of the common stock issued on May 20, 2023
3. The option, representing the right to purchase a total of 36,636 shares of InfuSystem Holdings, Inc. common stock, vests in three equal annual installments beginning May 18, 2024.
4. Restricted stock units convert into common stock on a one-for-one basis.
5. These restricted stock units will fully vest on May 18, 2026.
6. These restricted stock units fully vested on May 20, 2023.
Remarks:
/s/ Kevin Whitman, Attorney-in-Fact for Addam Chupa 05/22/2023
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* 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).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
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 Number.