FORM
4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities
Exchange Act of 1934 or Section 30(h) of the Investment Company Act of
1940
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OMB APPROVAL |
OMB Number: |
3235-0287 |
Expires: |
December 31, 2014 |
Estimated average burden |
hours per response: |
0.5 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue.
See
Instruction 1(b).
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1. Name and Address of Reporting Person
*
C/O INFUSYSTEM HOLDINGS, INC. |
31700 RESEARCH PARK DRIVE |
(Street)
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2. Issuer Name
and
Ticker or Trading Symbol
InfuSystem Holdings, Inc
[
INFU
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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3. Date of Earliest Transaction
(Month/Day/Year) 09/07/2017
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check
Applicable Line)
X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting
Person |
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Table I - Non-Derivative Securities Acquired, Disposed of, or
Beneficially Owned |
1.
Title of Security (Instr.
3)
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2.
Transaction Date
(Month/Day/Year) |
2A.
Deemed Execution Date, if any
(Month/Day/Year) |
3.
Transaction Code (Instr.
8)
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4.
Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported
Transaction(s) (Instr.
3 and 4)
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6.
Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7.
Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
Amount |
(A) or (D) |
Price |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Stock Option (right to buy)
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$
1.98
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09/07/2017 |
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A |
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25,000
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09/07/2022 |
Common Stock
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25,000
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$
0
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25,000
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D
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Explanation of Responses: |
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/s/Trent N. Smith, Attorney-in-Fact for Scott Shuda |
09/08/2017 |
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** Signature of Reporting Person |
Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
* If the form is filed by more than one reporting person,
see
Instruction
4
(b)(v). |
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
LIMITED POWER OF ATTORNEY FOR
SECTION 16 REPORTING OBLIGATIONS
KNOW ALL BY THESE PRESENTS, that the undersigned
hereby makes, constitutes and appoints each of Eric Steen,
Trent Smith and Christopher Downs, signing singly, as the
undersigned's true and lawful attorney-in-fact, with full
power and authority as hereinafter described on behalf of
and in the name, place and stead of the undersigned to:
(1) seek, obtain or maintain filing codes with the
United States Securities and Exchange Commission,
including submission of Form ID;
(2) prepare, execute, acknowledge, deliver and file
Forms 3, 4, and 5 (including any amendments thereto) with
respect to the securities of InfuSystem Holdings, Inc., a
Delaware corporation (the "Company"), with the United
States Securities and Exchange Commission, any national
securities exchanges and the Company, as considered
necessary or advisable under Section 16(a) of the
Securities Exchange Act of 1934 and the rules and
regulations promulgated thereunder, as amended from time
to time (the "Exchange Act");
(3) seek or obtain, as the undersigned's
representative and on the undersigned's behalf,
information on transactions in the Company's securities
from any third party, including brokers, employee benefit
plan administrators and trustees, and the undersigned
hereby authorizes any such person to release any such
information to the undersigned and approves and ratifies
any such release of information; and
(4) perform any and all other acts which in the
discretion of such attorney-in-fact are necessary or
desirable for and on behalf of the undersigned in
connection with the foregoing.
The undersigned acknowledges that:
(1) this Limited Power of Attorney authorizes, but
does not require, such attorney-in-fact to act in their
discretion on information provided to such attorney-in-
fact without independent verification of such information;
(2) any documents prepared and/or executed by such
attorney-in-fact on behalf of the undersigned pursuant to
this Limited Power of Attorney will be in such form and
will contain such information and disclosure as such
attorney-in-fact, in his or her discretion, deems
necessary or desirable;
(3) neither the Company nor such attorney-in-fact
assumes (i) any liability for the undersigned's
responsibility to comply with the requirement of the
Exchange Act, (ii) any liability of the undersigned for
any failure to comply with such requirements, or (iii) any
obligation or liability of the undersigned for profit
disgorgement under Section 16(b) of the Exchange Act; and
(4) this Limited Power of Attorney does not relieve
the undersigned from responsibility for compliance with
the undersigned's obligations under the Exchange Act,
including without limitation the reporting requirements
under Section 16 of the Exchange Act.
The undersigned hereby gives and grants the
foregoing attorney-in-fact full power and authority to do
and perform all and every act and thing whatsoever
requisite, necessary or appropriate to be done in and
about the foregoing matters as fully to all intents and
purposes as the undersigned might or could do if present,
hereby ratifying all that such attorney-in-fact of, for
and on behalf of the undersigned, shall lawfully do or
cause to be done by virtue of this Limited Power of
Attorney.
This Limited Power of Attorney shall remain in full
force and effect until revoked by the undersigned in a
signed writing delivered to such attorney-in-fact. This
Limited Power of Attorney shall be governed by, and
construed in accordance with, the laws of the state of
Delaware, excluding its conflicts of laws principles.
IN WITNESS WHEREOF, the undersigned has caused this
Limited Power of Attorney to be executed as of this
8th day of September, 2017.
Signature: /s/Scott Shuda
Print Name: Scott Shuda