SEC FORM 4

SEC Form 4

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^*

Dilorio Richard

(Last)

(First)

(Middle)

C/O INFUSYSTEM HOLDINGS, INC.

31700 RESEARCH PARK DRIVE

(Street)

MADISON HEIGHTS

48071

(City)

(State)

(Zip)

2. Issuer Name and Ticker or Trading Symbol
InfuSystem Holdings, Inc [ INFU ]

5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	10% Owner
X	Officer (give title below)	Other (specify below)
	Chief Executive Officer

3. Date of Earliest Transaction (Month/Day/Year)
11/15/2017

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)
1. Title of Security (Instr. 3)	2. Transaction Date (Month/Day/Year)	2A. Deemed Execution Date, if any (Month/Day/Year)	Code	V	Amount	(A) or (D)	Price		6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)
Common Stock								59,659	D

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)
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)	Code	V	(A)	(D)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	8. Price of Derivative Security (Instr. 5)		10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
Stock Option (right to buy)	$2.69							⁽¹⁾	07/14/2024	Common Stock	50,000		50,000	D
Stock Option (right to buy)	$2.6							⁽²⁾	03/11/2025	Common Stock	25,000		25,000	D
Stock Option (right to buy)	$2.76							⁽³⁾	08/16/2026	Common Stock	40,000		40,000	D
Stock Option (right to buy)	$2.15							⁽⁴⁾	03/16/2027	Common Stock	25,000		25,000	D
Stock Option (right to buy)	$1.98							⁽⁵⁾	09/07/2022	Common Stock	25,000		25,000	D
Stock Appreciation Rights	$2	11/15/2017		A		200,000		⁽⁶⁾	03/31/2019	Common Stock	200,000	$0	200,000	D
Stock Option (right to buy)	$2	11/15/2017		A		200,000		⁽⁷⁾	11/15/2022	Common Stock	200,000	$0	200,000	D

Explanation of Responses:

1. The option, representing the right to purchase a total of 50,000 shares of InfuSystem Holdings, Inc. common stock, vests in thirty-six monthly installments beginning August 14, 2014.

2. The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests in forty-eight monthly installments beginning April 11, 2015.

3. The option, representing the right to purchase a total of 40,000 shares of InfuSystem Holdings, Inc. common stock, vests in thirty-six monthly installments beginning September 16, 2016.

4. The option, representing the right to purchase a total of 25,000 shares of InfuSystems Holdings, Inc. common stock, vests in thirty-six monthly installments beginning April 16, 2017.

5. The option, representing the right to purchase a total of 25,000 shares of InfuSystem Holdings, Inc. common stock, vests annually over three years beginning September 7, 2018.

6. The stock appreciation rights shall vest and become exercisable beginning on December 31, 2018, based on certain company financial criteria.

7. The option, representing the right to purchase a total of 200,000 shares of InfuSystem Holdings, Inc. common stock, vests over four-year period on a monthly basis beginning December 15, 2017.

	/s/Trent N. Smith, Attorney-in-Fact for Richard Dilorio	12/12/2017
	** 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).
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