0001628280-23-019354.txt : 20230522
0001628280-23-019354.hdr.sgml : 20230522
20230522202329
ACCESSION NUMBER: 0001628280-23-019354
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20230518
FILED AS OF DATE: 20230522
DATE AS OF CHANGE: 20230522
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Malhotra R. Rimmy
CENTRAL INDEX KEY: 0001442755
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35020
FILM NUMBER: 23946258
MAIL ADDRESS:
STREET 1: C/O COMMAND CENTER, INC.
STREET 2: 3609 S WADSWORTH BLVD., SUITE 250
CITY: LAKEWOOD
STATE: CO
ZIP: 80235
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_168480139731546.xml
FORM 4
X0407
4
2023-05-18
0
0001337013
InfuSystem Holdings, Inc
INFU
0001442755
Malhotra R. Rimmy
C/O INFUSYSTEM HOLDINGS, INC.
3851 WEST HAMLIN ROAD
ROCHESTER HILLS
MI
48309
1
0
0
0
0
Common Stock
23225
D
Common Stock
222574
I
See FN
Stock Options (right to buy)
9.18
2023-05-18
4
A
0
24424
0
A
2024-05-18
2033-05-18
Common Stock
24424.0
24424
D
Represents shares directly owned by Nicoya Fund, LLC, a Delaware limited liability company. Mr. Malhotra is managing member of Nicoya Capital, LLC, which is the managing member of Nicoya Fund, LLC. Mr. Malhotra disclaims beneficial ownership of such shares except to the extent of his pecuniary interest therein.
The option, representing the right to purchase a total of 24,424 shares of InfuSystem Holdings, Inc. common stock, vests on May 18, 2024.
/s/ Kevin Whitman, Attorney-in-Fact for R. Rimmy Malhotra
2023-05-19