0001437749-19-006216.txt : 20190401
0001437749-19-006216.hdr.sgml : 20190401
20190401152915
ACCESSION NUMBER: 0001437749-19-006216
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20190328
FILED AS OF DATE: 20190401
DATE AS OF CHANGE: 20190401
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Dilorio Richard
CENTRAL INDEX KEY: 0001706994
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35020
FILM NUMBER: 19720357
MAIL ADDRESS:
STREET 1: 31700 RESEARCH PARK DRIVE
CITY: MADISON HEIGHTS
STATE: MI
ZIP: 48071
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
rdgdoc.xml
FORM 4
X0306
4
2019-03-28
0001337013
InfuSystem Holdings, Inc
INFU
0001706994
Dilorio Richard
31700 RESEARCH PARK DRIVE
MADISON HEIGHTS
MI
48071
1
1
President & CEO
Common Stock
2019-03-28
4
M
0
25000
A
117028
D
Common Stock
2019-03-28
4
F
0
7350
4.14
D
109678
D
Common Stock
2019-03-29
4
M
0
200000
2
A
309678
D
Common Stock
2019-03-29
4
F
0
117754
4.79
D
191924
D
Stock Appreciation Rights
2
2019-03-29
4
M
0
200000
0
D
2018-12-31
2019-03-31
Common Stock
200000
0
D
Restricted Stock Units
2019-03-28
4
M
0
25000
0
D
Common Stock
25000
100000
D
Represents the acquisition of the Issuer's common stock by reporting person pursuant to the vesting and settlement of a portion of the restricted stock units (RSUs) granted on August 23, 2018. Restricted stock units convert into common stock on a one-for-one basis.
Represents the withholding of the Issuer's common stock for the tax liability associated with the vesting and settlement of a portion of the restricted stock units (RSUs) granted on August 23, 2018.
Represents the acquisition of the Issuer's common stock by reporting person pursuant to the exercise of the Stock Appreciation Rights granted on November 15, 2017.
Represents the difference between the number of the Stock Appreciation Rights exercised and the number of shares issued as a result of the exercise.
Represents the withholding of the Issuer's common stock for the tax liability associated with the exercise of the Stock Appreciation Rights granted on November 15, 2017.
/s/ Richard DiIorio
2019-04-01