SEC Form 4 · accession 0001014108-17-000205
InfuSystem Holdings, Inc · INFU
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Richard Dilorio
Officer — Chief Executive Officer · Director
Period of report
Nov 15, 2017
Accepted (ET)
Dec 12, 2017 · 5:21 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001337013
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common Stock | holding | — | — | — | 59,659 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Stock Appreciation RightsF6 | $2.00 | Nov 15, 2017 | A | 200,000 | A | — | Mar 31, 2019 | Common Stock | 200,000 | 200,000 | D |
| Stock Option (right to buy)F7 | $2.00 | Nov 15, 2017 | A | 200,000 | A | — | Nov 15, 2022 | Common Stock | 200,000 | 200,000 | D |
| Stock Option (right to buy)F1 | $2.69 | holding | — | — | — | — | Jul 14, 2024 | Common Stock | 50,000 | 50,000 | D |
| Stock Option (right to buy)F2 | $2.60 | holding | — | — | — | — | Mar 11, 2025 | Common Stock | 25,000 | 25,000 | D |
| Stock Option (right to buy)F3 | $2.76 | holding | — | — | — | — | Aug 16, 2026 | Common Stock | 40,000 | 40,000 | D |
| Stock Option (right to buy)F4 | $2.15 | holding | — | — | — | — | Mar 16, 2027 | Common Stock | 25,000 | 25,000 | D |
| Stock Option (right to buy)F5 | $1.98 | holding | — | — | — | — | Sep 7, 2022 | Common Stock | 25,000 | 25,000 | D |
Explanation of responses
- F1The option, representing the right to purchase a total of 50,000 shares of InfuSystem Holdings, Inc. common stock, vests in thirty-six monthly installments beginning August 14, 2014.
- F2The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests in forty-eight monthly installments beginning April 11, 2015.
- F3The option, representing the right to purchase a total of 40,000 shares of InfuSystem Holdings, Inc. common stock, vests in thirty-six monthly installments beginning September 16, 2016.
- F4The option, representing the right to purchase a total of 25,000 shares of InfuSystems Holdings, Inc. common stock, vests in thirty-six monthly installments beginning April 16, 2017.
- F5The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests annually over three years beginning September 7, 2018.
- F6The stock appreciation rights shall vest and become exercisable beginning on December 31, 2018, based on certain company financial criteria.
- F7The option, representing the right to purchase a total of 200,000 shares of InfuSystem Holdings, Inc. common stock, vests over four-year period on a monthly basis beginning December 15, 2017.