SEC Form 4 · accession 0000950103-17-000179
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
Jan 3, 2017
Accepted (ET)
Jan 5, 2017 · 7:04 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 ValueF1,F2 | Jan 3, 2017 | A | 5,883 | $0.00 | A | 53,209 | D | |
| Common Stock, No Par ValueF2 | holding | — | — | — | 56,500 | I | By RCS Investments Inc. | |
| Common Stock, No Par ValueF3 | holding | — | — | — | 600,000 | I | By Stachowiak Equity Fund LLC |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1Deferred restricted stock units vesting equally over four (4) successive quarters from the transaction date, but not issued until termination of the reporting person's service to the issuer.
- F2The totals have been corrected from the amounts in the previous Form 4 to correct mathematical errors (including double-counting of 500 shares) in previous filings. The corrections resulted in an increase in total indirect holdings by 1,000 shares and a decrease in total direct holdings by 1,500 shares.
- F3Fund 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.