Initial Statement of Beneficial Ownership (3)
12 Maio 2023 - 1:36PM
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
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NEALE MATTHEW |
2. Date of Event Requiring Statement (MM/DD/YYYY)
5/4/2023
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3. Issuer Name and Ticker or Trading Symbol
AGILITI, INC. DE [AGTI]
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(Last)
(First)
(Middle)
C/O AGILITI, INC., 11095 VIKING 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)
SVP, Chief Information Officer / |
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(Street)
EDEN PRAIRIE, MN 55344
(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, $0.0001 par value | 8491 | D |
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| Common Stock, $0.0001 par value | 15 | I | By son |
| Common Stock, $0.0001 par value | 15 | I | By daughter |
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 |
| Options (Right to Buy) | (1) | 7/6/2031 | Common Stock, $0.0001 par value | 7520 | $21.61 | D |
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| Options (Right to Buy) | (2) | 3/3/2032 | Common Stock, $0.0001 par value | 8808 | $18.45 | D |
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| Options (Right to Buy) | (3) | 3/10/2033 | Common Stock, $0.0001 par value | 11103 | $14.83 | D |
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| Explanation of Responses: |
| (1) | The reporting person received 7,520 options under the Agiliti, Inc. Amended and Restated 2018 Omnibus Incentive Plan on July 6, 2021. The options vest ratably on each of July 6, 2022, July 6, 2023 and July 6, 2024, subject to the reporting person remaining in continuous employment with the issuer on the vesting date. |
| (2) | The reporting person received 8,808 options under the Agiliti, Inc. Amended and Restated 2018 Omnibus Incentive Plan on March 3, 2022. The options vest ratably on each of March 6, 2023, March 6, 2024 and March 6, 2025, subject to the reporting person remaining in continuous employment with the issuer on the vesting date. |
| (3) | The reporting person received 11,103 options under the Agiliti, Inc. Amended and Restated 2018 Omnibus Incentive Plan on March 10, 2023. The options vest ratably on each of March 10, 2024, March 10, 2025 and March 10, 2026, subject to the reporting person remaining in continuous employment with the issuer on the vesting date. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
NEALE MATTHEW
C/O AGILITI, INC.
11095 VIKING DRIVE, SUITE 300
EDEN PRAIRIE, MN 55344 |
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| SVP, Chief Information Officer |
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Signatures
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| /s/ Lee M. Neumann, by power of attorney | | 5/12/2023 |
| **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 control number. |
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