SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF 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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1. Name and Address of Reporting Person*
RUIZ THOMAS MARK

(Last) (First) (Middle)
31700 RESEARCH PARK DRIVE

(Street)
MADISON HEIGHTS MI 48071

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
02/12/2019
3. Issuer Name and Ticker or Trading Symbol
InfuSystem Holdings, Inc [ INFU ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
VP OF SALES AND MARKETING
5. 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
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock 5,337 D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Stock Option (Right to Buy) 07/31/2017 12/08/2024 Common Stock 50,000 2.69 D
Stock Option (Right to Buy) (1) 08/18/2026 Common Stock 40,000 2.76 D
Stock Option (Right to Buy) (2) 03/15/2027 Common Stock 25,000 2.15 D
Stock Option (Right to Buy) (3) 09/06/2022 Common Stock 25,000 1.98 D
Stock Option (Right to Buy) (4) 07/19/2023 Common Stock 25,000 3.36 D
Restricted Stock Units 03/11/2019(6) 03/12/2019(6) Common Stock 2,083 (5) D
Explanation of Responses:
1. The option, representing the right to purchase a total of 40,000 shares, became exercisable in 36 equal monthly installments following the August 18, 2016 date of grant.
2. The option, representing the right to purchase a total of 25,000 shares, became exercisable in 36 equal monthly installments following the March 16, 2017 date of grant.
3. Stock option vests 33% per year on anniversary date starting September 7, 2018
4. Stock option vests 33% per year on anniversary date starting July 19, 2019
5. Restricted stock units convert into common stock on a one-for-one basis.
6. The reporting person was awarded restricted stock units on March 11, 2015, which vest in one remaining annual installment on March 11th of 2019. Settlement of the underlying shares of common stock will occur on vesting date, assuming continued employment through the applicable vesting date.
/s/ Thomas M. Ruiz 02/20/2019
** 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 5 (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.