0001437749-19-010358.txt : 20190517
0001437749-19-010358.hdr.sgml : 20190517
20190517131811
ACCESSION NUMBER: 0001437749-19-010358
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 2
CONFORMED PERIOD OF REPORT: 20190515
FILED AS OF DATE: 20190517
DATE AS OF CHANGE: 20190517
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: RUIZ THOMAS MARK
CENTRAL INDEX KEY: 0001768484
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35020
FILM NUMBER: 19834985
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
2019-05-15
0001337013
InfuSystem Holdings, Inc
INFU
0001768484
RUIZ THOMAS MARK
31700 RESEARCH PARK DRIVE
MADISON HEIGHTS
MI
48071
1
VP OF SALES AND MARKETING
Stock Option (Right to Buy)
4.70
2019-05-15
4
A
0
40000
0
A
2029-05-15
Common Stock
40000
40000
D
Stock option vests 33% per year on anniversary date starting May 15, 2020.
/s/ Jeanie Latz, Attorney-in-Fact for Tom Ruiz
2019-05-17
EX-24
2
poaruiz.txt
LIMITED POWER OF ATTORNEY FOR
SECTION 16 REPORTING OBLIGATIONS
KNOW ALL BY THESE PRESENTS, that the undersigned hereby makes,
constitutes and appoints each of Richard DiIorio, Gregory Schulte and Jeanie
Latz, signing singly, as the undersigned's true and lawful attorney-in-fact,
with full power and authority as hereinafter described on behalf
of and in the name, place and stead of the undersigned to:
(1) seek, obtain or maintain filing codes with the United States
Securities and Exchange Commission, including submission of Form ID;
(2) prepare, execute, acknowledge, deliver and file Forms 3, 4,
and 5 (including any amendments thereto) with respect to the securities of
InfuSystem Holdings, Inc., a Delaware corporation (the "Company"), with the
United States Securities and Exchange Commission, any national securities
exchanges and the Company, as considered necessary or advisable under
Section 16(a) of the Securities Exchange Act of 1934 and the rules and
regulations promulgated thereunder, as amended from time to time (the
"Exchange Act");
(3) seek or obtain, as the undersigned's representative and on the
undersigned's behalf, information on transactions in the Company's securities
from any third party, including brokers, employee benefit plan administrators
and trustees, and the undersigned hereby authorizes any such person to
release any such information to the undersigned and approves and ratifies any
such release of information; and
(4) perform any and all other acts which in the discretion of such
attorney-in-fact are necessary or desirable for and on behalf of the
undersigned in connection with the foregoing.
The undersigned acknowledges that:
(1) this Limited Power of Attorney authorizes, but does not require,
such attorney-in-fact to act in their discretion on information provided to
such attorney-in-fact without independent verification of such information;
(2) any documents prepared and/or executed by such attorney-in-fact
on behalf of the undersigned pursuant to this Limited Power of Attorney
will be in such form and will contain such information and disclosure
as such attorney-in-fact, in his or her discretion, deems necessary
or desirable;
(3) neither the Company nor such attorney-in-fact assumes (i) any
liability for the undersigned's responsibility to comply with the
requirement of the Exchange Act, (ii) any liability of the undersigned
for any failure to comply with such requirements, or (iii) any
obligation or liability of the undersigned for profit disgorgement
under Section 16(b) of the Exchange Act; and
(4) this Limited Power of Attorney does not relieve the undersigned
from responsibility for compliance with the undersigned's obligations under
the Exchange Act, including without limitation the reporting requirements
under Section 16 of the Exchange Act.
The undersigned hereby gives and grants the foregoing attorney-in-fact
full power and authority to do and perform all and every act and thing
whatsoever requisite, necessary or appropriate to be done in and about the
foregoing matters as fully to all intents and purposes as the undersigned
might or could do if present, hereby ratifying all that such
attorney-in-fact of, for and on behalf of the undersigned, shall lawfully
do or cause to be done by virtue of this Limited Power of Attorney.
This Limited Power of Attorney shall remain in full force and
effect until revoked by the undersigned in a signed writing delivered to
such attorney-in-fact. This Limited Power of Attorney shall be governed
by, and construed in accordance with, the laws of the state of Delaware,
excluding its conflicts of laws principles.
IN WITNESS WHEREOF, the undersigned has caused this Limited Power of
Attorney to be executed as of this 15th day of February, 2019.
/s/ Thomas M. Ruiz
Print Name: Thomas M. Ruiz