0001609580-17-000003.txt : 20170629 0001609580-17-000003.hdr.sgml : 20170629 20170629182856 ACCESSION NUMBER: 0001609580-17-000003 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20170627 FILED AS OF DATE: 20170629 DATE AS OF CHANGE: 20170629 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: 17939820 MAIL ADDRESS: STREET 1: C/O ASHS STREET 2: 2 EMBARCADERO CENTER-SUITE 410 CITY: SAN FRANCISCO STATE: CA ZIP: 94111 4 1 primary_doc.xml PRIMARY DOCUMENT X0306 4 2017-06-27 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 2017-06-27 4 A 0 500 0 A 53709 D Common Stock, No Par Value 56500 I By RCS Investments Inc. Common Stock, No Par Value 600000 I By Stachowiak Equity Fund LLC Stock Options (right to buy) 3.9 2017-06-27 4 A 0 2000 0 A 2018-06-26 2024-06-26 Common Stock 2000 2000 D This represents an award of restricted stock units. Each unit will entitle the reporting person to one share of the issuer's common stock upon vesting. The units will vest in full upon the earlier of (I) the reporting person's completion of one year of service measured from June 27, 2017, or (II) such individual's continuation in Board service through the day immediately preceding the 2018 Annual Shareholders Meeting (the "Vesting Date"). Includes 500 shares subject to the reported restricted stock unit award which will vest in full on the Vesting Date. The reported stock option will vest in full upon the earlier of (I) the reporting person's completion of one year of service measured from June 27, 2017, or (II) such individual's continuation in Board service through the day immediately preceding the 2018 Annual Shareholders Meeting (the "Vesting Date"). /s/ Chloe Tagawa on behalf of Raymond C. Stachowiak 2017-06-29