Statement of Changes in Beneficial Ownership (4)
September 09 2020 - 2:13PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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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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1. Name and Address of Reporting Person
*
Stachowiak Raymond C |
2. Issuer Name and Ticker or Trading Symbol
AMERICAN SHARED HOSPITAL SERVICES
[
AMS
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director __X__ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Interim President & CEO |
(Last)
(First)
(Middle)
C/O ASHS, TWO EMBARCADERO CENTER, STE 410 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
9/4/2020 |
(Street)
SAN FRANCISCO, CA 94111-4107
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. 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
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V
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Amount
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(A) or (D)
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Price
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Common Stock, No Par Value (1) | 9/4/2020 | | A | | 10000 | A | $0 | 148061 | D | |
Common Stock, No Par Value | | | | | | | | 57000 | I | By RCS Investments Inc. |
Common Stock, No Par Value | | | | | | | | 760559 | I | By Stachowiak Equity Fund LLC |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. 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 | 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 of Derivative Security: 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 |
Explanation of Responses: |
(1) | 1. This represents an award of 10,000 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) October 3, 2020 or (ii) the appointment of the reporting person's successor as President and Chief Executive Officer. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Stachowiak Raymond C C/O ASHS TWO EMBARCADERO CENTER, STE 410 SAN FRANCISCO, CA 94111-4107 | X | X | Interim President & CEO |
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Signatures
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/s/ Craig K. Tagawa on behalf of Raymond C. Stachowiak | | 9/8/2020 |
**Signature of Reporting Person | Date |
American Shared Hospital... (AMEX:AMS)
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