SEC Form 4 · accession 0000731012-19-000023
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
Jan 2, 2019
Accepted (ET)
Jan 4, 2019 · 6:27 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 | Jan 2, 2019 | A | 621 | $34.15 | A | 133,709 | D | |
| Common Stock | Jan 4, 2019 | M | 6,000 | $0.00 | A | 139,709 | D | |
| Common Stock | Jan 4, 2019 | M | 6,000 | $0.00 | A | 145,709 | D | |
| Common StockF2 | Jan 4, 2019 | F | 3,424 | $0.00 | D | 142,285 | D |
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 | — | Jan 2, 2019 | A | 939 | A | — | — | Common Stock | 939 | 12,391 | D |
| Restricted Stock UnitsF3,F6 | — | Jan 4, 2019 | M | 6,000 | D | — | — | Common Stock | 6,000 | 18,000 | D |
| Restricted Stock UnitsF3,F7 | — | Jan 4, 2019 | M | 6,000 | D | — | — | Common Stock | 6,000 | 24,000 | D |
| Restricted Stock UnitsF3,F8 | — | Jan 4, 2019 | A | 42,500 | A | — | — | Common Stock | 42,500 | 42,500 | D |
| Stock Option (right to buy)F9 | $40.49 | Jan 4, 2019 | A | 50,000 | A | — | Jan 4, 2029 | Common Stock | 50,000 | 50,000 | D |
Explanation of responses
- F1Acquired by the Reporting Person through participation in the Healthcare Services Group, Inc. Employee Stock Purchase Plan.
- F2Total Direct and Indirect Beneficial Ownership by Reporting Person is 258,055.
- F3Shares issued at the conversion rate of 1-for-1.
- 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 Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
- F7These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2018 grant date.
- F8These Restricted Stock Units shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2019 grant date.
- F9These options shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2019 grant date.