SEC Form 4 · accession 0000731012-15-000024
HEALTHCARE SERVICES GROUP INC · HCSG
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Theodore Wahl
Officer — President and COO · Director
Period of report
Dec 31, 2014
Accepted (ET)
Jan 5, 2015 · 5:27 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000731012
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1,F2 | Jan 5, 2015 | A | 7,500 | $0.00 | A | 92,005 | D | |
| Common StockF2 | Jan 5, 2015 | A | 0 | $0.00 | A | 79,008 | I | Held by spouse |
| Common StockF2 | Jan 5, 2015 | A | 0 | $0.00 | A | 23,623 | I | Held by minor child |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Phantom StockF4,F3,F5 | $0.00 | Dec 31, 2014 | A | 1,234 | A | Dec 31, 2014 | — | Common Stock | 1,234 | 1,234 | D |
| Stock Option (right to buy)F6 | $30.30 | Jan 5, 2015 | A | 15,000 | A | Jan 5, 2020 | Jan 5, 2025 | Common Stock | 15,000 | 15,000 | D |
Explanation of responses
- F1Represents shares of Restricted Stock Awards granted to the Reporting Person, pursuant to the Healthcare Services Group, Inc. 2012 Equity Incentive Plan.
- F2Total Direct and Indirect Beneficial Ownership by Reporting Person is 194,636 shares.
- F3Shares issued at conversion rate of 1-for-1 basis.
- F4Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan.
- F5Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer.
- F6These options shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary from the date set forth in Table II, Column 3.