| FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 01/01/2021 | 3. Issuer Name and Ticker or Trading Symbol HEALTHCARE SERVICES GROUP INC [ HCSG ] | |||||||||||||
| 4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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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 | 3,357 | D | |
| Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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| 1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: 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) | (2) | (2) | Common Stock | 1,041 | 0.0 | D | |
| Restricted Stock Units | (3) | (3) | Common Stock | 1,500 | 0.0 | D | |
| Restricted Stock Units | (4) | (4) | Common Stock | 600 | 0.0 | D | |
| Restricted Stock Units | (5) | (5) | Common Stock | 3,080 | 0.0 | D | |
| Restricted Stock Units | (6) | (6) | Common Stock | 6,445 | 0.0 | D | |
| Stock Option (right to buy) | (7) | 01/05/2025 | Common Stock | 800 | 30.3 | D | |
| Stock Option (right to buy) | (8) | 01/04/2026 | Common Stock | 2,400 | 34.14 | D | |
| Stock Option (right to buy) | (9) | 01/04/2027 | Common Stock | 4,000 | 39.38 | D | |
| Stock Option (right to buy) | (10) | 01/04/2028 | Common Stock | 5,000 | 52.06 | D | |
| Stock Option (right to buy) | (11) | 01/04/2029 | Common Stock | 5,000 | 40.49 | D | |
| Stock Option (right to buy) | (12) | 01/03/2030 | Common Stock | 8,523 | 24.43 | D | |
| Explanation of Responses: |
| 1. Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan. |
| 2. Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer. |
| 3. These Restricted Stock Units vest at the rate of 20% annually, commencing on each calendar anniversary after the award's January 4, 2017 grant date, and as such, 2,250 of these awards have already vested. |
| 4. These Restricted Stock Units vest at the rate of 20% annually, commencing on each calendar anniversary after the award's January 4, 2018 grant date, and as such, 400 of these awards have already vested. |
| 5. These Restricted Stock Units vest at the rate of 20% annually, commencing on each calendar anniversary after the award's January 4, 2019 grant date, and as such, 770 of these awards have already vested. |
| 6. These Restricted Stock Units vest at the rate of 20% annually, commencing on each calendar anniversary after the award's January 3, 2020 grant date. |
| 7. These options have fully vested. |
| 8. These options shall vest and become exercisable at the rate of 20% annually, commencing on each calendar anniversary of the option's January 4, 2016 grant date, and as such, 1,600 of these options have already vested and are exercisable. |
| 9. These options shall vest and become exercisable at the rate of 20% annually, commencing on each calendar anniversary of the option's January 4, 2017 grant date, and as such, 2,000 of these options have already vested and are exercisable. |
| 10. These options shall vest and become exercisable at the rate of 20% annually, commencing on each calendar anniversary of the option's January 4, 2018 grant date, and as such, 2,000 of these options have already vested and are exercisable. |
| 11. These options shall vest and become exercisable at the rate of 20% annually, commencing on each calendar anniversary of the option's January 4, 2019 grant date, and as such, 1,000 of these options have already vested and are exercisable. |
| 12. These options shall vest and become exercisable at the rate of 20% annually, commencing on each calendar anniversary of the option's January 3, 2020 grant date. |
| Remarks: |
| John C. Shea, by Power of Attorney | 01/04/2021 | |
| ** Signature of Reporting Person | Date | |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
| * If the form is filed by more than one reporting person, see Instruction 5 (b)(v). | ||
| ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
| 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 Number. | ||
