SEC Form 4 · accession 0001014108-18-000192
InfuSystem Holdings, Inc · INFU
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Scott Shuda
Director
Period of report
Aug 23, 2018
Accepted (ET)
Aug 27, 2018 · 5:14 pm EDT
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 | — | — | — | 0 | D | ||
| Common StockF1 | holding | — | — | — | 3,346,834 | I | See footnote |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Stock Option (right to buy)F2 | $3.18 | Aug 23, 2018 | A | 25,000 | A | — | Aug 23, 2023 | Common Stock | 25,000 | 25,000 | D |
Explanation of responses
- F1Mr. Shuda serves as the Managing Director of (i) TSV Investment Partners, LLC ("TSV"), which is the sole general partner of Meridian OHC Partners, LP ("Meridian") and (ii) BlueLine Partners, LLC, which is the sole general partner of BlueLine Capital Partners II, LP ("BlueLine"), which together are the Company's largest stockholder. Accordingly, Mr. Shuda holds voting and dispositive power over the Common Stock held by Meridian and BlueLine. Mr. Shuda disclaims beneficial ownership for purposes of Rule 13d-3 with respect to the Common Stock held by Meridian and BlueLine.
- F2The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests in twelve monthly installments beginning on September 23, 2018.