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FORM 5
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/ / 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
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<S> <C> <C> <C> <C> <C> <C>
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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
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TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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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)
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Common Stock 2/98 423,062 D
(See Note 1)
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*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)
<S> <C> <C> <C> <C> <C> <C> <C>
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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
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<C> <C> <C> <C>
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)
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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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