0001014108-17-000159.txt : 20170912
0001014108-17-000159.hdr.sgml : 20170912
20170912122051
ACCESSION NUMBER: 0001014108-17-000159
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 2
CONFORMED PERIOD OF REPORT: 20170907
FILED AS OF DATE: 20170912
DATE AS OF CHANGE: 20170912
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Sansone Christopher R.
CENTRAL INDEX KEY: 0001519525
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35020
FILM NUMBER: 171080519
MAIL ADDRESS:
STREET 1: C/O SANSONE ADVISORS, LLC
STREET 2: 151 BODMAN PLACE, SUITE 100
CITY: RED BANK
STATE: NJ
ZIP: 07701
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: InfuSystem Holdings, Inc
CENTRAL INDEX KEY: 0001337013
STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841]
IRS NUMBER: 203341405
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 31700 RESEARCH PARK DRIVE
CITY: MADISON HEIGHTS
STATE: MI
ZIP: 48071
BUSINESS PHONE: (248) 291-1210
MAIL ADDRESS:
STREET 1: 31700 RESEARCH PARK DRIVE
CITY: MADISON HEIGHTS
STATE: MI
ZIP: 48071
FORMER COMPANY:
FORMER CONFORMED NAME: HAPC, Inc.
DATE OF NAME CHANGE: 20060425
FORMER COMPANY:
FORMER CONFORMED NAME: Healthcare Acquisition Partners Corp.
DATE OF NAME CHANGE: 20050824
4
1
primary_doc.xml
PRIMARY DOCUMENT
X0306
4
2017-09-07
0
0001337013
InfuSystem Holdings, Inc
INFU
0001519525
Sansone Christopher R.
C/O INFUSYSTEM HOLDINGS, INC.
31700 RESEARCH PARK DRIVE
MADISON HEIGHTS
MI
48071
1
0
0
0
Stock Option (right to buy)
1.98
2017-09-07
4
A
0
25000
0
A
2022-09-07
Common Stock
25000
25000
D
The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests in twelve monthly installments beginning October 7, 2017.
/s/Trent N. Smith, Attorney-in-Fact for Christopher R. Sansone
2017-09-08
EX-24
2
sansonepoa.txt
POWER OF ATTORNEY
LIMITED POWER OF ATTORNEY FOR
SECTION 16 REPORTING OBLIGATIONS
KNOW ALL BY THESE PRESENTS, that the undersigned
hereby makes, constitutes and appoints each of Eric Steen,
Trent Smith and Christopher Downs, signing singly, as the
undersigned's true and lawful attorney-in-fact, with full
power and authority as hereinafter described on behalf of
and in the name, place and stead of the undersigned to:
(1) seek, obtain or maintain filing codes with the
United States Securities and Exchange Commission,
including submission of Form ID;
(2) prepare, execute, acknowledge, deliver and file
Forms 3, 4, and 5 (including any amendments thereto) with
respect to the securities of InfuSystem Holdings, Inc., a
Delaware corporation (the "Company"), with the United
States Securities and Exchange Commission, any national
securities exchanges and the Company, as considered
necessary or advisable under Section 16(a) of the
Securities Exchange Act of 1934 and the rules and
regulations promulgated thereunder, as amended from time
to time (the "Exchange Act");
(3) seek or obtain, as the undersigned's
representative and on the undersigned's behalf,
information on transactions in the Company's securities
from any third party, including brokers, employee benefit
plan administrators and trustees, and the undersigned
hereby authorizes any such person to release any such
information to the undersigned and approves and ratifies
any such release of information; and
(4) perform any and all other acts which in the
discretion of such attorney-in-fact are necessary or
desirable for and on behalf of the undersigned in
connection with the foregoing.
The undersigned acknowledges that:
(1) this Limited Power of Attorney authorizes, but
does not require, such attorney-in-fact to act in their
discretion on information provided to such attorney-in-
fact without independent verification of such information;
(2) any documents prepared and/or executed by such
attorney-in-fact on behalf of the undersigned pursuant to
this Limited Power of Attorney will be in such form and
will contain such information and disclosure as such
attorney-in-fact, in his or her discretion, deems
necessary or desirable;
(3) neither the Company nor such attorney-in-fact
assumes (i) any liability for the undersigned's
responsibility to comply with the requirement of the
Exchange Act, (ii) any liability of the undersigned for
any failure to comply with such requirements, or (iii) any
obligation or liability of the undersigned for profit
disgorgement under Section 16(b) of the Exchange Act; and
(4) this Limited Power of Attorney does not relieve
the undersigned from responsibility for compliance with
the undersigned's obligations under the Exchange Act,
including without limitation the reporting requirements
under Section 16 of the Exchange Act.
The undersigned hereby gives and grants the
foregoing attorney-in-fact full power and authority to do
and perform all and every act and thing whatsoever
requisite, necessary or appropriate to be done in and
about the foregoing matters as fully to all intents and
purposes as the undersigned might or could do if present,
hereby ratifying all that such attorney-in-fact of, for
and on behalf of the undersigned, shall lawfully do or
cause to be done by virtue of this Limited Power of
Attorney.
This Limited Power of Attorney shall remain in full
force and effect until revoked by the undersigned in a
signed writing delivered to such attorney-in-fact. This
Limited Power of Attorney shall be governed by, and
construed in accordance with, the laws of the state of
Delaware, excluding its conflicts of laws principles.
IN WITNESS WHEREOF, the undersigned has caused this
Limited Power of Attorney to be executed as of this
15th day of August, 2017.
Signature: /s/Christopher R. Sansone
Print Name: Christopher R. Sansone