SEC Form 4 · accession 0000731012-16-000107
HEALTHCARE SERVICES GROUP INC · HCSG
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Theodore Wahl
Officer — President & CEO · Director
Period of report
Dec 31, 2015
Accepted (ET)
Jan 5, 2016 · 4:47 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 4, 2016 | A | 15,000 | $0.00 | A | 107,853 | D | |
| Common StockF3,F2 | Jan 4, 2016 | A | 793 | $26.29 | A | 108,646 | D | |
| Common StockF2 | Jan 4, 2016 | A | 0 | $0.00 | A | 81,901 | I | Held by spouse |
| Common StockF2 | Jan 4, 2016 | A | 0 | $0.00 | A | 26,168 | 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 StockF5,F4,F6 | $0.00 | Dec 31, 2015 | A | 1,082 | A | Dec 31, 2015 | — | Common Stock | 1,082 | 1,082 | D |
| Stock Option (right to buy)F7 | $34.14 | Jan 4, 2016 | A | 15,000 | A | Jan 4, 2021 | Jan 4, 2026 | 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 216,715 shares.
- F3Acquired in 2016 by the Reporting Person through participation in the 2015 Healthcare Services Group, Inc. Employee Stock Purchase Plan
- F4Shares issued at conversion rate of 1-for-1 basis.
- F5Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan.
- F6Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer.
- F7These 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.