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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
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 |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Meridian OHC Partners, LP 425 WEED STREET NEW CANAAN, CT 06840 |
X | X | ||
Meridian TSV II, LP 425 WEED STREET NEW CANAAN, CT 06840 |
X | X | ||
TSV Investment Partners, LLC 425 WEED STREET NEW CANAAN, CT 06840 |
X | X | ||
BlueLine Capital Partners II, L.P. 3480 BUSKIRK AVENUE SUITE 214 PLEASANT HILL, CA 94523 |
X | X | ||
BlueLine Partners, L.L.C. 3480 BUSKIRK AVENUE SUITE 214 PLEASANT HILL, CA 94523 |
X | X |
/s/ Scott A. Shuda | 08/25/2017 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | These securities are owned by BlueLine Capital Partners II, LP. As described in the Schedule 13D filing made on February 12, 2016 with respect to the Common Stock owned by Meridian OHC Partners, LP, Meridian TSV II, LP, TSV Investment Partners, LLC, BlueLine Capital Partners II, L.P. and BlueLine Partners, L.L.C., the Reporting Entities may have been deemed to be a "group" under Section 13(d) of the Securities Exchange Act and accordingly each Reporting Person may have been deemed to have beneficial ownership of 10% or more of the Common Stock. The price reported in Column 4 is a weighted average price. These shares reported herein were purchased in multiple transactions. The reporting persons undertake to provide to InfuSystem Holdings, Inc., any security holder of InfuSystem Holdings, Inc., or the staff of the Securities and Exchange Commission, upon request, full information regarding the number of shares purchased at each separate price. |