0001209191-12-002664.txt : 20120109 0001209191-12-002664.hdr.sgml : 20120109 20120109074701 ACCESSION NUMBER: 0001209191-12-002664 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20120105 FILED AS OF DATE: 20120109 DATE AS OF CHANGE: 20120109 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SHEA JOHN CHRISTOPHER CENTRAL INDEX KEY: 0001502211 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-12015 FILM NUMBER: 12515984 MAIL ADDRESS: STREET 1: 3220 TILLMAN DRIVE STREET 2: SUITE 300 CITY: BENSALEM STATE: PA ZIP: 19020 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: HEALTHCARE SERVICES GROUP INC CENTRAL INDEX KEY: 0000731012 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-TO DWELLINGS & OTHER BUILDINGS [7340] IRS NUMBER: 232018365 STATE OF INCORPORATION: PA FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2643 HUNTINGDON PIKE CITY: HUNTINGDON VALLEY STATE: PA ZIP: 19006 BUSINESS PHONE: 2159381661 MAIL ADDRESS: STREET 1: 2643 HUNTINGDON PIKEE CITY: HUNTINGDON VALLEY STATE: PA ZIP: 19006 4 1 doc4.xml FORM 4 SUBMISSION X0304 4 2012-01-05 0 0000731012 HEALTHCARE SERVICES GROUP INC HCSG 0001502211 SHEA JOHN CHRISTOPHER 3220 TILLMAN DRIVE SUITE 300 BENSALEM PA 19020 0 1 0 0 Chief Accounting Officer Phantom stock 0.00 2012-01-05 4 A 0 311 17.69 A 2012-01-05 common stock 311 311 D Stock option 17.50 2012-01-05 4 A 0 1000 0.00 A 2013-01-05 2022-01-05 common stock 1000 1000 D Stock option 17.50 2012-01-05 4 A 0 1000 0.00 A 2014-01-05 2022-01-05 common stock 1000 2000 D Stock option 17.50 2012-01-05 4 A 0 1000 0.00 A 2015-01-05 2022-01-05 common stock 1000 3000 D Stock option 17.50 2012-01-05 4 A 0 1000 0.00 A 2016-01-05 2022-01-05 common stock 1000 4000 D Stock option 17.50 2012-01-05 4 A 0 1000 0.00 A 2017-01-05 2022-01-05 common stock 1000 5000 D SHARES ISSUED AT CONVERSION RATE OF 1 FOR 1 ACQUIRED PURSANT TO AN ISSUER CONTRIBUTION UNDER THE HEALTHCARE SERVICES GROUP, INC DEFERRED COMPENSATION PLAN SHARES OF PHANTOM STOCK ARE PAYABLE IN KIND FOLLOWING TERMINATION OF THE REPORTING PERSON'S EMPLOYMENT WITH ISSUER /s/ John C. Shea 2012-01-09