Form 4 Salveson Jon W

4 - Statement of changes in beneficial ownership of securities

Published: 2018-05-29 16:50:12
Submitted: 2018-05-29
Period Ending In: 2018-05-25
primary_doc.html PRIMARY DOCUMENT


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SEC FORM 4

SEC Form 4
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
OMB APPROVAL
OMB Number: 3235-0287
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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*
Salveson Jon W

(Last) (First) (Middle)
800 NICOLLET MALL

(Street)
MINNEAPOLIS MN 55402

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
CHF Solutions, Inc. [ CHFS ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
05/25/2018
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Nonstatutory Stock Option (right to buy) $3.01 05/25/2018 A 10,000 (1) 05/24/2028 Common Stock 10,000 $0 10,000 D
Explanation of Responses:
1. Vests in 12 approximately equal consecutive monthly increments, commencing on the one-month anniversary of the date of grant, so that all of the options will be vested on the one-year anniversary of the date of grant.
/s/ Gayle Aiken, by Power of Attorney 05/29/2018
** 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.
1
primary_doc.xml PRIMARY DOCUMENT
Schema Version:
X0306
Document Type:
4
Period Of Report:
2018-05-25
Not Subject To Section16:
0

Issuer

Issuer Cik
0001506492
Issuer Name
CHF Solutions, Inc.
Issuer Trading Symbol
CHFS

Reporting Owner

Reporting Owner Id

Rpt Owner Cik
0001372026
Rpt Owner Name
Salveson Jon W

Reporting Owner Address

Rpt Owner Street1
800 NICOLLET MALL
Rpt Owner City
MINNEAPOLIS
Rpt Owner State
MN
Rpt Owner Zip Code
55402

Reporting Owner Relationship

Is Director
1
Is Officer
0
Is Ten Percent Owner
0
Is Other
0

Derivative Transaction

Security Title
Nonstatutory Stock Option (right to buy)
Conversion Or Exercise Price
3.01
Transaction Date
2018-05-25

Transaction Coding

Transaction Form Type
4
Transaction Code
A
Equity Swap Involved
0

Transaction Amounts

Transaction Shares
10000
Transaction Price Per Share
0
Transaction Acquired Disposed Code
A
@attributes Id
F1
Expiration Date
2028-05-24

Underlying Security

Underlying Security Title
Common Stock
Underlying Security Shares
10000
Shares Owned Following Transaction
10000
Direct Or Indirect Ownership
D
Footnotes Footnote
Vests in 12 approximately equal consecutive monthly increments, commencing on the one-month anniversary of the date of grant, so that all of the options will be vested on the one-year anniversary of the date of grant.

Owner Signature

Signature Name
/s/ Gayle Aiken, by Power of Attorney
Signature Date
2018-05-29
Additional Files
FileSequenceDescriptionTypeSize
0001596771-18-000065.txt   Complete submission text file   5324
$CHFS

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