SEC Form 4 · accession 0000731012-18-000017
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
Nov 15, 2017
Accepted (ET)
Jan 4, 2018 · 8:55 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 Stock | Nov 15, 2017 | G | 1,450 | $49.77 | A | 115,161 | D | |
| Common Stock | Nov 15, 2017 | G | 528 | $49.77 | A | 85,064 | I | Held by spouse |
| Common Stock | Nov 15, 2017 | G | 1,584 | $49.77 | A | 30,002 | I | Held by minor child |
| Common StockF1 | Dec 29, 2017 | G | 200 | $52.72 | D | 84,864 | I | Held by spouse |
| Common StockF2 | Jan 2, 2018 | A | 637 | $33.29 | A | 115,798 | D | |
| Common Stock | Jan 4, 2018 | M | 6,000 | $52.06 | A | 121,798 | D | |
| Common StockF1 | Jan 4, 2018 | F | 1,710 | $52.06 | D | 120,088 | D |
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)F3 | $52.06 | Jan 4, 2018 | A | 50,000 | A | — | Jan 4, 2028 | Common Stock | 50,000 | 50,000 | D |
| Restricted Stock UnitsF4,F5 | — | Jan 4, 2018 | A | 30,000 | A | — | — | Common Stock | 30,000 | 30,000 | D |
| Restricted Stock UnitsF4,F6 | — | Jan 4, 2018 | M | 6,000 | D | — | — | Common Stock | 6,000 | 24,000 | D |
| Phantom StockF7,F4,F8 | — | Jan 3, 2018 | A | 715 | A | — | — | Common Stock | 715 | 11,126 | D |
Explanation of responses
- F1Total Direct and Indirect Beneficial Ownership by Reporting Person is 234,954.
- F2Acquired by the Reporting Person through participation in the Healthcare Services Group, Inc. Employee Stock Purchase Plan.
- F3These options shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2018 grant date.
- F4Shares issued at the conversion rate of 1-for-1.
- F5These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2018 grant date.
- F6These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
- F7Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan.
- F8Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer.