0001628280-23-024142.txt : 20230703 0001628280-23-024142.hdr.sgml : 20230703 20230703183549 ACCESSION NUMBER: 0001628280-23-024142 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230630 FILED AS OF DATE: 20230703 DATE AS OF CHANGE: 20230703 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: 231066259 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_168842373768421.xml FORM 4 X0407 4 2023-06-30 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 0 Common Stock 2023-06-30 4 M 0 25000 3.36 A 156095 D Common Stock 2023-06-30 4 F 0 12729 9.57 D 143366 D Stock Option (right to buy) 3.36 2023-06-30 4 M 0 25000 0 D 2019-07-19 2023-07-18 Common Stock 25000.0 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 25,000 shares of InfuSystem Holdings, Inc. common stock, vests 33% per year on the anniversary starting July 19, 2019. /s/ Kevin Whitman, Attorney-in-Fact for Carrie Lachance 2023-07-03