0001628280-23-019359.txt : 20230522 0001628280-23-019359.hdr.sgml : 20230522 20230522202656 ACCESSION NUMBER: 0001628280-23-019359 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: Chupa Addam CENTRAL INDEX KEY: 0001953233 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35020 FILM NUMBER: 23946265 MAIL ADDRESS: STREET 1: 3851 WEST HAMLIN ROAD CITY: ROCHESTER HILLS STATE: MI ZIP: 48309 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_168480160424134.xml FORM 4 X0407 4 2023-05-18 0 0001337013 InfuSystem Holdings, Inc INFU 0001953233 Chupa Addam C/O INFUSYSTEM HOLDINGS, INC. 3851 WEST HAMLIN ROAD ROCHESTER HILLS MI 48309 0 1 0 0 Executive VP and CIO 0 Common Stock 2023-05-20 4 M 0 2500 0 A 19481 D Common Stock 2023-05-20 4 F 0 1015 9.12 D 18466 D Stock Options (right to buy) 9.18 2023-05-18 4 A 0 36636 0 A 2033-05-18 Common Stock 36636.0 36636 D Restricted Stock Units 2023-05-18 4 A 0 5447 0 A 2026-05-18 Common Stock 5447.0 5447 D Restricted Stock Units 2023-05-20 4 M 0 2500 0 D Common Stock 2500.0 0 D Vesting of restricted stock award granted on May 20, 2020 Represents the withholding of the Issuer's common stock for the tax liability associated with the vesting and settlement of the common stock issued on May 20, 2023 The option, representing the right to purchase a total of 36,636 shares of InfuSystem Holdings, Inc. common stock, vests in three equal annual installments beginning May 18, 2024. Restricted stock units convert into common stock on a one-for-one basis. These restricted stock units will fully vest on May 18, 2026. These restricted stock units fully vested on May 20, 2023. /s/ Kevin Whitman, Attorney-in-Fact for Addam Chupa 2023-05-22