0001014108-18-000192.txt : 20180827
0001014108-18-000192.hdr.sgml : 20180827
20180827171448
ACCESSION NUMBER: 0001014108-18-000192
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20180823
FILED AS OF DATE: 20180827
DATE AS OF CHANGE: 20180827
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Shuda Scott
CENTRAL INDEX KEY: 0001486636
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35020
FILM NUMBER: 181039537
MAIL ADDRESS:
STREET 1: 402 RAILROAD AVENUE, SUITE 201
CITY: DANVILLE
STATE: CA
ZIP: 94526
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: InfuSystem Holdings, Inc
CENTRAL INDEX KEY: 0001337013
STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841]
IRS NUMBER: 203341405
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 31700 RESEARCH PARK DRIVE
CITY: MADISON HEIGHTS
STATE: MI
ZIP: 48071
BUSINESS PHONE: (248) 291-1210
MAIL ADDRESS:
STREET 1: 31700 RESEARCH PARK DRIVE
CITY: MADISON HEIGHTS
STATE: MI
ZIP: 48071
FORMER COMPANY:
FORMER CONFORMED NAME: HAPC, Inc.
DATE OF NAME CHANGE: 20060425
FORMER COMPANY:
FORMER CONFORMED NAME: Healthcare Acquisition Partners Corp.
DATE OF NAME CHANGE: 20050824
4
1
primary_doc.xml
PRIMARY DOCUMENT
X0306
4
2018-08-23
0
0001337013
InfuSystem Holdings, Inc
INFU
0001486636
Shuda Scott
31700 RESEARCH PARK DRIVE
MADISON HEIGHTS
MI
48071
1
0
0
0
Common Stock
0
D
Common Stock
3346834
I
See footnote
Stock Option (right to buy)
3.18
2018-08-23
4
A
0
25000
0
A
2023-08-23
Common Stock
25000
25000
D
Mr. Shuda serves as the Managing Director of (i) TSV Investment Partners, LLC ("TSV"), which is the sole general partner of Meridian OHC Partners, LP ("Meridian") and (ii) BlueLine Partners, LLC, which is the sole general partner of BlueLine Capital Partners II, LP ("BlueLine"), which together are the Company's largest stockholder. Accordingly, Mr. Shuda holds voting and dispositive power over the Common Stock held by Meridian and BlueLine. Mr. Shuda disclaims beneficial ownership for purposes of Rule 13d-3 with respect to the Common Stock held by Meridian and BlueLine.
The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests in twelve monthly installments beginning on September 23, 2018.
/s/Scott Shuda
2018-08-27