Statement of Changes in Beneficial Ownership (4)
June 04 2021 - 5:56PM
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
*
BRIGGS JOHN |
2. Issuer Name and Ticker or Trading Symbol
HEALTHCARE SERVICES GROUP INC
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HCSG
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
3220 TILLMAN DRIVE, SUITE 300 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
6/1/2021 |
(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 | 6/1/2021 | | A | | 1307 | A | $30.61 (1) | 21474 (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 |
Explanation of Responses: |
(1) | Represents a grant of unvested deferred stock units ("DSU") granted under the Issuer's 2020 Omnibus Incentive Plan which will become fully vested on the one year anniversary of the grant date. Such DSUs will be settled in shares of common stock on the first to occur of (i) five-year anniversary of the Date of Grant, (ii) the Participant's date of death, disability or separation from service; or (iii) the date of a Change of Control (the "Settlement Date"). A Participant may elect a further deferral beyond the Settlement Date pursuant to the rules of Code Section 409A. |
(2) | Amount represents 20,167 shares of common shares held, and 1,307 unvested DSUs |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
BRIGGS JOHN 3220 TILLMAN DRIVE SUITE 300 BENSALEM, PA 19020 | X |
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Signatures
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/s/ Michael Harrity, by Power of Attorney | | 6/4/2021 |
**Signature of Reporting Person | Date |
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