Initial Statement of Beneficial Ownership (3)
April 21 2017 - 4:45PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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
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Kush Andrew
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2. Date of Event Requiring Statement (MM/DD/YYYY)
4/11/2017
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3. Issuer Name
and
Ticker or Trading Symbol
HEALTHCARE SERVICES GROUP INC [HCSG]
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(Last)
(First)
(Middle)
3220 TILLMAN DRIVE, SUITE 300
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
Executive Vice President /
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(Street)
BENSALEM, PA 19020
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
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X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common Stock
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660
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D
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Phantom Stock
(1)
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(2)
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(2)
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Common Stock
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1820.0
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$0.0
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D
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Restricted Stock
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(3)
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(3)
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Common Stock
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140.0
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$0.0
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D
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Restricted Stock
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(4)
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(4)
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Common Stock
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375.0
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$0.0
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D
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Restricted Stock
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(5)
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(5)
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Common Stock
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800.0
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$0.0
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D
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Restricted Stock Units
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(6)
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(6)
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Common Stock
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8500.0
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$0.0
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D
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Stock Option (right to buy)
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(7)
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1/6/2021
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Common Stock
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2000.0
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$16.11
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D
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Stock Option (right to buy)
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(7)
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1/5/2022
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Common Stock
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5000.0
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$17.5
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D
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Stock Option (right to buy)
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(8)
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1/4/2023
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Common Stock
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5000.0
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$23.5
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D
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Stock Option (right to buy)
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(9)
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1/3/2024
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Common Stock
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5000.0
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$28.02
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D
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Stock Option (right to buy)
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(10)
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1/5/2025
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Common Stock
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5000.0
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$30.3
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D
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Stock Option (right to buy)
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(11)
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1/4/2026
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Common Stock
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6000.0
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$34.14
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D
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Stock Option (right to buy)
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(12)
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1/4/2027
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Common Stock
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6000.0
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$39.38
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D
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Explanation of Responses:
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(1)
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Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan.
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(2)
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Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer.
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(3)
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These Restricted Stock Awards shall vest at the rate of 20% annually, commencing on the first anniversary of the January 3, 2014 grant date, and as such, 210 of these awards have already vested.
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(4)
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These Restricted Stock Awards shall vest at the rate of 20% annually, commencing on the first anniversary of the January 5, 2015 grant date, and as such, 250 of these awards have already vested.
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(5)
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These Restricted Stock Awards shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2016 grant date, and as such, 200 of these awards have already vested.
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(6)
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These Restricted Stock Units shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
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(7)
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These options have fully vested.
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(8)
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These options vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2013 grant date.
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(9)
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These options vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 3, 2014 grant date.
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(10)
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These options vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 5, 2015 grant date.
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(11)
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These options vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2016 grant date.
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(12)
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These options shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Kush Andrew
3220 TILLMAN DRIVE
SUITE 300
BENSALEM, PA 19020
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Executive Vice President
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Signatures
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John C. Shea, by Power of Attorney
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4/21/2017
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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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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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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