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