SEC Form 4 · accession 0000731012-17-000011
HEALTHCARE SERVICES GROUP INC · HCSG
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Jason J Bundick
Officer — General Counsel & Secretary
Period of report
Dec 31, 2016
Accepted (ET)
Jan 4, 2017 · 8:31 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000731012
Table I — non-derivative securities
No Table I lines on this filing.
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)F1 | $39.38 | Jan 4, 2017 | A | 6,000 | A | Jan 4, 2022 | Jan 4, 2027 | Common Stock | 6,000 | 6,000 | D |
| Restricted Stock UnitsF2,F3 | — | Jan 4, 2017 | A | 8,500 | A | Jan 4, 2022 | — | Common Stock | 8,500 | 8,500 | D |
| Phantom StockF4,F2,F5 | — | Dec 31, 2016 | A | 257 | A | Dec 31, 2016 | — | Common Stock | 257 | 257 | D |
Explanation of responses
- F1These options shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
- F2Shares issued at the conversion rate of 1-for-1.
- F3These Restricted Stock Units shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
- 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.