Statement of Changes in Beneficial Ownership (4)
January 06 2021 - 6:53PM
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
*
WAHL Theodore |
2. Issuer Name and Ticker or Trading Symbol
HEALTHCARE SERVICES GROUP INC
[
HCSG
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) President & CEO |
(Last)
(First)
(Middle)
3220 TILLMAN DRIVE, SUITE 300 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
1/4/2021 |
(Street)
BENSALEM, PA 19020
(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 | 1/4/2021 | | A | | 1025 (1) | A | $20.67 | 216668 | D | |
Common Stock | 1/4/2021 | | M | | 6000 | A | $0 | 222668 | D | |
Common Stock | 1/4/2021 | | M | | 6000 | A | $0 | 228668 | D | |
Common Stock | 1/4/2021 | | M | | 8500 | A | $0 | 237168 | D | |
Common Stock | 1/4/2021 | | M | | 15548 | A | $0 | 252716 | D | |
Common Stock | 1/4/2021 | | F | | 14302 | D | $0 | 238414 (2) | D | |
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 |
Phantom Stock | (3) | 1/4/2021 | | A | | 2219 | | (4) | (4) | Common Stock | 2219.0 | $28.10 | 18228 (5) | D | |
Stock Option (right to buy) | $28.37 | 1/4/2021 | | A | | 103193 | | (6) | 1/4/2031 | Common Stock | 103193.0 | $28.37 | 103193 | D | |
Restricted Stock Units | (3) | 1/4/2021 | | A | | 50123 | | (7) | (7) | Common Stock | 50123.0 | $0 | 50123 | D | |
Restricted Stock Units | (3) | 1/4/2021 | | M | | | 6000 | (8) | (8) | Common Stock | 6000.0 | $0 | 6000 | D | |
Restricted Stock Units | (3) | 1/4/2021 | | M | | | 6000 | (9) | (9) | Common Stock | 6000.0 | $0 | 12000 | D | |
Restricted Stock Units | (3) | 1/4/2021 | | M | | | 8500 | (10) | (10) | Common Stock | 8500.0 | $0 | 25500 | D | |
Restricted Stock Units | (3) | 1/4/2021 | | M | | | 15548 | (11) | (11) | Common Stock | 15548.0 | $0 | 62188 | D | |
Explanation of Responses: |
(1) | Acquired by the Reporting Person through participation in the Healthcare Services Group, Inc. Employee Stock Purchase Plan. |
(2) | Total direct and indirect beneficial ownership by reporting person is 359,876 |
(3) | Shares issued at the conversion rate of 1-for-1. |
(4) | Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer. |
(5) | Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan. |
(6) | These options shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2021 grant date. |
(7) | These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2021 grant date. |
(8) | These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date. |
(9) | These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2018 grant date. |
(10) | These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2019 grant date. |
(11) | These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 3, 2020 grant date. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
WAHL Theodore 3220 TILLMAN DRIVE SUITE 300 BENSALEM, PA 19020 | X |
| President & CEO |
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Signatures
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/s/ John C. Shea | | 1/6/2021 |
**Signature of Reporting Person | Date |
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