| FORM 5 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ANNUAL 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 |
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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). | |||||||||||||||||
| Form 3 Holdings Reported. | |||||||||||||||||
| Form 4 Transactions Reported. | |||||||||||||||||
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
PROVIDENCE SERVICE CORP [ PRSC ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Statement for Issuer's Fiscal Year Ended
(Month/Day/Year) 12/31/2008 | ||||||||||||||||||||||||||
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4. If Amendment, Date of Original Filed
(Month/Day/Year) 02/17/2009 |
6. Individual or Joint/Group Filing (Check Applicable Line)
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| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | |||||||||||||||
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| 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 at end of Issuer's Fiscal Year (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||||||
| Amount | (A) or (D) | Price | |||||||||||||
| Common Stock | 11/20/2008 | L | 487 | A | $1.34 | 2,292,895 | D | ||||||||
| Common Stock | 2,292,895(1) | I | By 73114 | ||||||||||||
| Common Stock | 2,292,895(2) | I | By 73114 | ||||||||||||
| Common Stock | 7,200(3) | D | |||||||||||||
| Common Stock | 2,292,895(4) | I | By 73114 | ||||||||||||
| Common Stock | 1,000(5) | D | |||||||||||||
| Common Stock | 2,292,895(6) | I | By 73114 | ||||||||||||
| Common Stock | 1,000(7) | D | |||||||||||||
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | ||||||||||||||
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| 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) | |||
| (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | |||||||||
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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| Explanation of Responses: |
| 1. Avalon Correctional Services, Inc. ("Avalon") (Joint Reporting Person), the sole member of 73114 Investments, LLC ("73114"). |
| 2. Donald E. Smith and Tiffany D. Smith (Joint Reporting Persons), each of whom is a manager of 73114. Mr. Smith is also a director, officer and shareholder of Avalon, and Mrs. Smith is an officer and shareholder of Avalon. |
| 3. Shares owned by Donald E. Smith and Tiffany D. Smith, as joint tenants. |
| 4. Michael Bradley (Joint Reporting Person), is a manager of 73114 and an officer and shareholder of Avalon. |
| 5. Shares owned by Michael Bradley. |
| 6. Eric S. Gray (Joint Reporting Person), is a manager of 73114 and an officer and shareholder of Avalon. |
| 7. Shares owned by Eric S. Gray. |
| Remarks: |
| 13(d) Group owning more than 10%. This Form 5 is filed jointly for 73114 Investments, L.L.C. ("73114") and the other reporting persons identified in the footnotes to Table 1, all of whom have the address listed in Item 1. This Form 5/A is filed to add Michael Bradley to the list of Reporting Persons. Mr. Bradley's ownership was disclosed in Form 5; however he was inadvertently omitted from the list of Reporting Persons. The power of attorney is incorporated by reference to Exhibit 24.1 to the Amendment No. 2 to Schedule 13D filed for the reporting persons on February 13, 2009. |
| 73114 Investments, L.L.C., /s/ Eric S. Gray, Vice Pres./Manager and as Attorney-in-Fact for the other reporting persons | 02/17/2009 | |
| ** 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. | ||