Form 4 AMERICAN SHARED HOSPITAL For: Jun 21 Filed by: Stachowiak Raymond C

August 2, 2019 7:02 PM
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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person *
Stachowiak Raymond C

(Last) (First) (Middle)
2 EMBARCADERO CENTER
SUITE 410

(Street)
SAN FRANCISCO CA 94111

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
AMERICAN SHARED HOSPITAL SERVICES [ AMS ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
06/21/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock, No Par Value 06/21/2019 A 500 (1) A $ 0 69,717 (2) D
Common Stock, No Par Value 57,500 I By RCS Investments Inc.
Common Stock, No Par Value 760,559 I By Stachowiak Equity Fund LLC
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Stock Options (right to buy) $ 3.03 06/21/2019 A 2,000 06/20/2020 (3) 06/20/2026 Common stock 2,000.00 $ 0 2,000 D
Explanation of Responses:
1. This represents an award of restricted stock units. Each unit will entitle the reporting person to one share of the issuer's common stock upon vesting. The units will vest in full upon the earlier of (I) the reporting person's completion of one year of service measured from June 21, 2019, or (II) such individual's continuation in Board service through the day immediately preceding the 2020 Annual Shareholders Meeting (the "Vesting Date").
2. Includes 500 shares subject to the reported restricted stock unit award which will vest in full on the Vesting Date.
3. The reported stock option will vest in full upon the earlier of (I) the reporting person's completion of one year of service measured from June 21, 2019, or (II) such individual's continuation in Board service through the day immediately preceding the 2020 Annual Shareholders Meeting (the "Vesting Date").
/s/ Craig K. Tagawa on behalf of Raymond C. Stachowiak 08/02/2019
** 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).
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