-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, DK4057geFoODSGmQ6HwqfSrukAcMVuTQ2zJCItX4e/y7J+2m8T2jFvo3TwHjAxGt BvfUo2UH2V6WPUjSXnINgQ== 0000950144-99-001953.txt : 19990217 0000950144-99-001953.hdr.sgml : 19990217 ACCESSION NUMBER: 0000950144-99-001953 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19981231 FILED AS OF DATE: 19990216 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: PROVINCE HEALTHCARE CO CENTRAL INDEX KEY: 0001044942 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-GENERAL MEDICAL & SURGICAL HOSPITALS, NEC [8062] IRS NUMBER: 621710772 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 000-23639 FILM NUMBER: 99543239 BUSINESS ADDRESS: STREET 1: 105 WESTPARK DR STREET 2: STE 400 CITY: BRENTWOOD STATE: TN ZIP: 37027 BUSINESS PHONE: 6153701377 MAIL ADDRESS: STREET 1: 105 WESTPARK DR SUITE 180 STREET 2: 105 WESTPARK DR SUITE 180 CITY: BRENTWOOD STATE: TN ZIP: 37207 COMPANY DATA: COMPANY CONFORMED NAME: GORE RICHARD D CENTRAL INDEX KEY: 0001057320 STANDARD INDUSTRIAL CLASSIFICATION: [] OFFICER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 109 WESTPARK DR STREET 2: STE 180 CITY: BRENTWOOD STATE: TN ZIP: 37027 MAIL ADDRESS: STREET 1: 109 WESTPARK DR STREET 2: STE 180 CITY: BRENTWOOD STATE: TN ZIP: 37027 5 1 PROVINCE HEALTHCARE COMPANY 1 - ------ FORM 5 - ------ / / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION longer subject to WASHINGTON, DC 20549 Section 16. Form 4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP obligations may continue. See Filed pursuant to Section 16(a) of the Securities Instruction 1(b) Exchange Act of 1934, /X/ Form 3 Holdings Section 17(a) of the Public Utility Reported Holding Company Act of 1935 or Section 30(f) of / / Form 4 the Investment Company Act Transactions of 1940 Reported - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to Gore Richard D. Province Healthcare Company (PRHC) Issuer (Check all applicable) - ------------------------------------------- ---------------------------------------------- Director 10% Owner (Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- --- 105 Westwood Place, Suite 400 Number of Reporting Month/Year X Officer (give Other (specify - ------------------------------------------- Person (Voluntary) 12/98 ---- title --- below) (Street) ------------------- below) Brentwood TN 37027 5. If Amendment, Executive Vice President & CFO - ------------------------------------------- Date of Original ------------------------------- (City) (State) (Zip) (Month/Year) 7. Individual or Joint/Group Filing ------------------ (Check applicable line) X Form Filed by one ---- Reporting Person Form Filed by more than ---- one Reporting Person - ------------------------------------------------------------------------------------------------------------------------------------ TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Issuer's Direct Benefi- (Month/ Fiscal Year (D) or cial Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner- Year) Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 2/98 423,062 D (See Note 1) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ *If the form is filed by more than one reporting person, see instruction 4(b)(v). Potential persons who are not to 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. (Over) SEC 2270 (7-97)
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FORM 5 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price Security sion or action action Derivative cisable and of Underlying of (Instr. 3) Exercise Date Code Securities Expiration Securities Deriv- Price of (Month/ (Instr. Acquired (A) Date (Instr. 3 and 4) ative Deriv- Day/ 8) or Disposed (Month/Day/ Secur- ative Year) of (D) Year) ity Security (Instr. 3, (Instr. 5) 4, and 5) ----------------------------------- Date Expira- Amount or --------------- Exer- tion Title Number of (A) (D) cisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------- 1. Title of Derivative 9. Number of 10. Ownership 11. Nature of Security Derivative of Derivative Indirect (Instr. 3) Securities Security: Beneficial Beneficially Direct (D) Ownership Owned at End or Indirect (I) (Instr. 4) of Year (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- Explanation of Responses: Note 1: Correction to the total number of shares of Common Stock owned directly by the Reporting Person as reported on a Form 3 filed on February 9, 1998, which reflects the automatic conversion of 782,412 shares of the Issuer's Series B Junior Preferred Stock into 48,901 shares of Common Stock at the Issuer's initial public offering of Common Stock on February 10, 1998. **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Richard D. Gore 2/16/99 See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- ------- **Signature of Reporting Person Date Note. File three copies of this Form, one of which must be manually signed. If space provided is insufficient, see Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required Page 2 to respond unless the form displays a currently valid OMB number. SEC 2270(7-97)
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