SEC FORM
3
SEC Form 3
| 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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| 209 10TH AVE. SOUTH |
| SUITE 450 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
06/16/2014
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3. Issuer Name and Ticker or Trading Symbol
HEALTHSTREAM INC
[ HSTM ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| Senior Vice President |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock |
0 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
| Remarks: |
|
|
Thomas Schultz |
06/18/2014 |
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** 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. |
LIMITED POWER OF ATTORNEY FOR
SECTION 16 REPORTING OBLIGATIONS
KNOW ALL MEN BY THESE PRESENTS, that Thomas Schultz has made, constituted and
appointed, and by these presents does make, constitute and appoint Gerard Hayden
or Scott Roberts as its true and lawful attorney-in-fact, for its and in its
name, place and stead, and for its use and benefit, to do all things and to
execute all documents necessary to ensure compliance with Section 16 reporting
requirements associated with my relationship with HealthStream, Inc.
It is my intention by this instrument to grant unto said attorney-in-fact full
power and authority to do and perform all and every act and thing whatsoever to
accomplish the foregoing grant of power as shall be necessary to be done on my
behalf as fully to all intents and purposes as I might or could do if I was
present in person.
This power of attorney may be revoked by the undersigned only by specific
revocation endorsed or written hereon, and until such revocation be endorsed or
written hereon, all persons may rely upon this power of attorney as being in
full force and effect.
IN WITNESS WHEREOF, I have hereunto set my hand, the 16th day of June, 2014.
/s/Thomas Schultz
