SEC Form 4 · accession 0000950103-16-017983
AMERICAN SHARED HOSPITAL SERVICES · AMS
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Raymond C Stachowiak
Director · 10% Owner
Period of report
Nov 15, 2016
Accepted (ET)
Nov 17, 2016 · 7:21 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000744825
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common Stock, No Par Value | Nov 15, 2016 | M | 100,000 | $2.20 | A | 255,500 | I | By RCS Investments Inc. |
| Common Stock, No Par Value | Nov 15, 2016 | G | 200,000 | $0.00 | D | 55,500 | I | By RCS Investments Inc. |
| Common Stock, No Par ValueF1 | Nov 15, 2016 | G | 200,000 | $0.00 | A | 600,000 | I | By Stachowiak Equity Fund LLC |
| Common Stock, No Par Value | holding | — | — | — | 48,826 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Warrants (right to purchase) | $2.20 | Nov 15, 2016 | M | 100,000 | D | Oct 22, 2015 | Oct 22, 2017 | Common Stock | 100,000 | 0 | I |
Explanation of responses
- F1Fund is 60% controlled by a trust with the reporting person as sole trustee and beneficiary, and 20% each by two trusts established for the benefit of the reporting person's children, with the spouse of the reporting person as sole trustee of each.