| FORM 4 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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| Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | |||||||||||||||||
1. Name and Address of Reporting Person*
(Street)
| 2. Issuer Name and Ticker or Trading Symbol HEALTHCARE SERVICES GROUP INC [ HCSG ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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| 3. Date of Earliest Transaction (Month/Day/Year) 01/04/2021 | ||||||||||||||||||||||||||
| 4. 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 Acquired, Disposed of, or Beneficially Owned | ||||||||||
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| 1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
| Code | V | Amount | (A) or (D) | Price | ||||||
| Common Stock | 01/04/2021 | A | 769(1) | A | $20.67 | 4,126 | D | |||
| Common Stock | 01/04/2021 | M | 750 | A | $0 | 4,876 | D | |||
| Common Stock | 01/04/2021 | M | 200 | A | $0 | 5,076 | D | |||
| Common Stock | 01/04/2021 | M | 770 | A | $0 | 5,846 | D | |||
| Common Stock | 01/04/2021 | M | 1,290 | A | $0 | 7,136 | D | |||
| Common Stock | 01/04/2021 | F | 1,343 | D | $0 | 5,793 | D | |||
| Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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| 1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction 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 (Month/Day/Year) | 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: 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 | (2) | 01/04/2021 | A | 700(3) | (4) | (4) | Common Stock | 700 | $28.1 | 1,748(3) | D | ||||
| Stock Option (right to buy) | $28.37 | 01/04/2021 | A | 15,421 | (5) | 01/04/2031 | Common Stock | 15,421 | $28.37 | 15,421 | D | ||||
| Restricted Stock Units | (2) | 01/04/2021 | A | 7,490 | (6) | (6) | Common Stock | 7,490 | $0 | 7,490 | D | ||||
| Restricted Stock Units | (2) | 01/04/2021 | M | 750 | (7) | (7) | Common Stock | 750 | $0 | 750(8) | D | ||||
| Restricted Stock Units | (2) | 01/04/2021 | M | 200 | (9) | (9) | Common Stock | 200 | $0 | 400(8) | D | ||||
| Restricted Stock Units | (2) | 01/04/2021 | M | 770 | (10) | (10) | Common Stock | 770 | $0 | 2,310(8) | D | ||||
| Restricted Stock Units | (2) | 01/04/2021 | M | 1,290 | (11) | (11) | Common Stock | 1,290 | $0 | 5,155(8) | D | ||||
| Explanation of Responses: |
| 1. Acquired by the Reporting Person through participation in the Healthcare Services Group, Inc. Employee Stock Purchase Plan. |
| 2. Shares issued at the conversion rate of 1-for-1. |
| 3. Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan. |
| 4. Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer. |
| 5. 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. |
| 6. These Restricted Stock Units shall vest 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, 2017 grant date. |
| 8. This grant was made prior to the Reporting Person becoming a Section 16(a) filer, and as of the date of filing, a portion of this grant has already vested. |
| 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. |
| Remarks: |
| John C. Shea, by Power of Attorney | 01/06/2021 | |
| ** 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 4 (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. | ||
