0001628280-22-015081.txt : 20220520
0001628280-22-015081.hdr.sgml : 20220520
20220520181613
ACCESSION NUMBER: 0001628280-22-015081
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20220518
FILED AS OF DATE: 20220520
DATE AS OF CHANGE: 20220520
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Lachance Carrie
CENTRAL INDEX KEY: 0001790024
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35020
FILM NUMBER: 22949108
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: 3851 WEST HAMLIN ROAD
CITY: ROCHESTER HILLS
STATE: MI
ZIP: 48309
BUSINESS PHONE: (248) 291-1210
MAIL ADDRESS:
STREET 1: 3851 WEST HAMLIN ROAD
CITY: ROCHESTER HILLS
STATE: MI
ZIP: 48309
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
wf-form4_165308495006894.xml
FORM 4
X0306
4
2022-05-18
0
0001337013
InfuSystem Holdings, Inc
INFU
0001790024
Lachance Carrie
C/O INFUSYSTEM HOLDINGS, INC.
3851 WEST HAMLIN ROAD
ROCHESTER HILLS
MI
48309
1
1
0
0
President and COO
Common Stock
2022-05-18
4
M
0
2821
0
A
101333
D
Common Stock
2022-05-18
4
F
0
1111
8.45
D
100222
D
Common Stock
2022-05-18
4
A
0
9744
0
A
109966
D
Common Stock
2022-05-18
4
F
0
3805
8.45
D
106161
D
Restricted Stock Units
2022-05-18
4
M
0
2821
0
D
Common Stock
2821.0
0
D
Represents the withholding of the Issuer's common stock for the tax liability associated with the vesting and settlement of the common stock issued on May 18, 2022
On May 18, 2022, 9,744 performance-based restricted stock units, granted on May 18, 2021, vested
Restricted stock units convert into common stock on a one-for-one basis.
These restricted stock units cliff vested on May 18, 2022.
/s/ Kevin Whitman, Attorney-in-Fact for Carrie Lachance
2022-05-20