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