0001628280-22-024410.txt : 20220906 0001628280-22-024410.hdr.sgml : 20220906 20220906185013 ACCESSION NUMBER: 0001628280-22-024410 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220902 FILED AS OF DATE: 20220906 DATE AS OF CHANGE: 20220906 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Lachance Carrie CENTRAL INDEX KEY: 0001790024 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35020 FILM NUMBER: 221229497 MAIL ADDRESS: STREET 1: 31700 RESEARCH PARK DRIVE CITY: MADISON HEIGHTS STATE: MI ZIP: 48071 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: 3851 WEST HAMLIN ROAD CITY: ROCHESTER HILLS STATE: MI ZIP: 48309 BUSINESS PHONE: (248) 291-1210 MAIL ADDRESS: STREET 1: 3851 WEST HAMLIN ROAD CITY: ROCHESTER HILLS STATE: MI ZIP: 48309 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 wf-form4_166250459764619.xml FORM 4 X0306 4 2022-09-02 0 0001337013 InfuSystem Holdings, Inc INFU 0001790024 Lachance Carrie C/O INFUSYSTEM HOLDINGS, INC. 3851 WEST HAMLIN ROAD ROCHESTER HILLS MI 48309 1 1 0 0 President and COO Common Stock 2022-09-02 4 M 0 10000 1.98 A 125076 D Common Stock 2022-09-02 4 F 0 4364 7.77 D 120712 D Common Stock 2022-09-02 4 M 0 7500 1.98 A 128212 D Common Stock 2022-09-02 4 F 0 3273 7.77 D 124939 D Stock Option (right to buy) 1.98 2022-09-02 4 M 0 10000 0 D 2018-09-07 2022-09-06 Common Stock 10000.0 0 D Stock Option (right to buy) 1.98 2022-09-02 4 M 0 7500 0 D 2018-09-07 2022-09-06 Common Stock 7500.0 0 D Reflects the number of shares surrendered in connection with the cashless exercise and tax withholding obligations for the exercised option. The option, representing the right to purchase a total of 10,000 shares of InfuSystem Holdings, Inc. common stock, vests 50% per year on the anniversary starting September 7, 2018. The option, representing the right to purchase a total of 7,500 shares of InfuSystem Holdings, Inc. common stock, vests 33% per year on the anniversary starting September 7, 2018. /s/ Kevin Whitman, Attorney-in-Fact for Carrie Lachance 2022-09-06