0000950103-17-000179.txt : 20170105 0000950103-17-000179.hdr.sgml : 20170105 20170105190444 ACCESSION NUMBER: 0000950103-17-000179 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20170103 FILED AS OF DATE: 20170105 DATE AS OF CHANGE: 20170105 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AMERICAN SHARED HOSPITAL SERVICES CENTRAL INDEX KEY: 0000744825 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MEDICAL LABORATORIES [8071] IRS NUMBER: 942918118 STATE OF INCORPORATION: CA FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2 EMBARCADERO CENTER STREET 2: SUITE 410 CITY: SAN FRANCISCO STATE: CA ZIP: 94111 BUSINESS PHONE: 415-788-5300 MAIL ADDRESS: STREET 1: 2 EMBARCADERO CENTER STREET 2: SUITE 410 CITY: SAN FRANCISCO STATE: CA ZIP: 94111 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Stachowiak Raymond C CENTRAL INDEX KEY: 0001609580 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-08789 FILM NUMBER: 17512440 MAIL ADDRESS: STREET 1: C/O ASHS STREET 2: 2 EMBARCADERO CENTER-SUITE 410 CITY: SAN FRANCISCO STATE: CA ZIP: 94111 4 1 dp71746_4-stachowiak.xml FORM 4 X0306 4 2017-01-03 0 0000744825 AMERICAN SHARED HOSPITAL SERVICES AMS 0001609580 Stachowiak Raymond C C/O ASHS 2 EMBARCADERO CENTER-SUITE 410 SAN FRANCISCO CA 94111 1 0 1 0 Common Stock, No Par Value 2017-01-03 4 A 0 5883 0 A 53209 D Common Stock, No Par Value 56500 I By RCS Investments Inc. Common Stock, No Par Value 600000 I By Stachowiak Equity Fund LLC Deferred restricted stock units vesting equally over four (4) successive quarters from the transaction date, but not issued until termination of the reporting person's service to the issuer. The totals have been corrected from the amounts in the previous Form 4 to correct mathematical errors (including double-counting of 500 shares) in previous filings. The corrections resulted in an increase in total indirect holdings by 1,000 shares and a decrease in total direct holdings by 1,500 shares. Fund is 60% controlled by a trust with the reporting person as sole trustee and beneficiary, and 20% each by two trusts established for the benefit of the reporting person's children, with the spouse of the reporting person as sole trustee of each. /s/ Chloe Tagawa on behalf of Raymond C. Stachowiak 2017-01-05