Initial Statement of Beneficial Ownership (3)
March 08 2021 - 5:24PM
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
*
Brophy Andrew M |
2. Date of Event Requiring Statement (MM/DD/YYYY)
2/25/2021
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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 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) Acting Accounting Officer / |
(Street)
BENSALEM, PA 19020
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 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 Beneficially Owned
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1.Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 120 | 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. 4) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Phantom Stock | (1) | (1) | Common Stock | 370.0 | (2) | D | |
Restricted Stock Units | (3) | (3) | Common Stock | 73.0 | (2) | D | |
Restricted Stock Units | (4) | (4) | Common Stock | 491.0 | (2) | D | |
Restricted Stock Units | (5) | (5) | Common Stock | 705.0 | (2) | D | |
Explanation of Responses: |
(1) | Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer. |
(2) | Shares issued at the conversion rate of 1-for-1. |
(3) | These Restricted Stock Units shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2019 grant date. |
(4) | These Restricted Stock Units shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 3, 2020 grant date. |
(5) | These Restricted Stock Units shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2021 grant date. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Brophy Andrew M 3220 TILLMAN DRIVE SUITE 300 BENSALEM, PA 19020 |
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| Acting Accounting Officer |
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Signatures
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/s/ Andrew M. Brophy | | 3/8/2021 |
**Signature of Reporting Person | Date |
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