FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
InfuSystem Holdings, Inc [ INFU ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 11/22/2017 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Common Stock | 11/22/2017 | P | 3,998 | A | $2.155 | 1,275,404 | D(1) | |||
Common Stock | 11/22/2017 | P | 1,000 | A | $2.155 | 267,486 | D(2) | |||
Common Stock | 1,483,548 | I | See(3) | |||||||
Common Stock | 1,483,548 | I | See(3) | |||||||
Common Stock | 1,483,548 | I | See(3) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
1. The reported securities are directly owned by Sansone Partners, L.P., a Delaware limited partnership. |
2. The reported securities are directly owned by Sansone Partners (QP), L.P., a Delaware limited partnership. |
3. The reported securities are directly owned by (i) Sansone Partners, L.P., a Delaware limited partnership (the "3c1 Partnership"), and (ii) Sansone Partners (QP), L.P., a Delaware limited partnership (the "3c7 Partnership", and together with the 3c1 Partnership, the "Partnerships"), and may be deemed to be indirectly beneficially owned by Sansone Advisors, LLC, a Delaware limited liability company, as the investment manager of Partnerships (the "Investment Manager"), and by Sansone Capital Management, LLC, a Delaware limited liability company, as general partner of the Partnerships (the "General Partner"). The reported securities may also be deemed to be indirectly beneficially owned by Christopher Sansone as the managing member of the Investment Manager and the General Partner. The Reporting Persons disclaim beneficial ownership of the reported securities except to the extent of his or its pecuniary interest therein. |
/s/Trent N. Smith, Attorney-in-Fact for Christopher R. Sansone | 11/27/2017 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |