2017-09-15T10:34:07-05:00 2016-12-31 010494526 BAKER NEWMAN NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2016-01-01 046835128 PROVIDENTIA PRIMA TRUST PROV 9786546363 100 AMES POND DRIVE TEWKSBURY MA 01876 JOHN AHLE CHIEF FINANCIAL OFFICER 9786546363 2017-09-11 1 E DREW CHENEY P00182972 8002447444 2017-09-11 208.105.168.164 2017-09-11 10:17:21 ED P E1A65C102B06E5C9ADAF8DC78101520DB9B2CC9D 1AE51AD8AF7B3D1D93FB22ABE9BF8674BE35D3BF 2016 2021-01-29 14:40:06Z JOHN AHLE 100 AMES POND DRIVE TEWKSBURY MA 01876 10692905 0 X COVENANTHEATH.NET X 1996 MA PROVIDENTIA PRIMA WAS ESTABLISHED TO HOLD AND MANAGE POOLED INVESTMENTS OF VARIOUS ORGANIZATIONS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501 (C) (3) 8 6 0 0 0 0 0 0 0 0 10319410 5469710 23803 68543 10343213 5538253 0 0 0 0 0 0 0 0 0 838319 700464 838319 700464 9504894 4837789 238250753 239803223 243682 172550 238007071 239630673 PROVIDENTIA PRIMA WAS ESTABLISHED TO HOLD AND MANAGE POOLED INVESTMENTS OF VARIOUS ORGANIZATIONS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501 (C) (3). 0 0 N/A 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 8 6 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X X JOHN AHLE 9786546363 100 AMES POND DRIVE TEWKSBURY MA 01876 JOHN AHLE TREASURER/SECRETARY 1.00 39.00 X X 0 738263 36019 CAROLYN KASABIAN TRUSTEE THRU 5/16 1.00 39.00 X 0 262121 12428 DONALD M DEHART CHAIR/PRESIDENT 3.00 X X 0 0 0 RICHARD J PLAMONDON VICE PRESIDENT 1.00 39.00 X X 0 326752 32428 WILLIAM ADAMS TRUSTEE 1.00 X 0 0 0 KEVIN HALLORAN TRUSTEE 1.00 X 0 0 0 WILLIAM DEMASO TRUSTEE 1.00 X 0 0 0 SR CATHERINE O'CONNOR TO 1216 TRUSTEE 1.00 X 0 0 0 ROSEMARIE CONNOLLY TRUSTEE 1.00 X 0 0 0 PAUL ARENBURG TRUSTEE 1.00 X 0 0 0 0 1327136 80875 0 0 1 0 NEPC LLC 255 STATE STREET BOSTON MA 02109 INVESTMENT ADVISOR 166704 SILCHESTER INTERNATIONAL INVESTORS 780 3RD AVENUE 42ND FLOOR NEW YORK NY 10017 INVESTMENT MANAGER 153058 IRONBRIDGE CAPITAL MANAGEMENT LP ONE PARKVIEW PL SUITE 700 OAKBROOK TERRACE IL 60181 INVESTMENT MANAGER 120471 3 5008080 5008080 5616282 5154652 461630 461630 461630 OTHER 900099 68543 68543 68543 5538253 0 0 5538253 30000 30000 584056 584056 ADMINISTRATION EXPENSE 60000 60000 MISCELLANEOUS EXPENSES 26408 26408 700464 0 700464 0 5250061 6463866 175305765 170152355 57684583 63172466 10344 14536 238250753 239803223 243682 172550 243682 172550 X 0 0 0 0 238007071 239630673 238007071 239630673 238250753 239803223 X 4837789 10733739 -13947926 X 0 1 X 1 0 X X 1 COVENANT HEALTH INC 222484505 10 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 PART IV, SECTION B, LINE 2 THE SUPPORTING ORGANIZATION OPERATES EXCLUSIVELY FOR THE BENEFIT, AND TO CARRY OUT SOME OR ALL THE PURPOSES, OF THE CORPORATE MEMBER (COVENANT HEALTH) AND IN THE DISCRETION OF THE CORPORATE MEMBER AND BOARD OF DIRECTORS, TO SUPPORT OTHER NOT FOR PROFIT RELIGIOUS, EDUCATIONAL AND CHARITABLE ORGANIZATIONS THAT ARE RELATED TO THE SOLE CORPORATE MEMBER. 0 ALTERNATIVE INVESTMENTS 63172466 F 63172466 X PART X, LINE 2: COVENANT AND ITS MEMBER ORGANIZATIONS ARE CONSIDERED NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE, EXCEPT AS NOTED BELOW. TAX-EXEMPT ORGANIZATIONS COULD BE REQUIRED TO RECORD AN OBLIGATION FOR INCOME TAXES AS THE RESULT OF A TAX POSITION THEY HAVE HISTORICALLY TAKEN ON VARIOUS TAX EXPOSURE ITEMS INCLUDING UNRELATED BUSINESS INCOME OR TAX STATUS. UNDER GUIDANCE ISSUED BY THE FINANCIAL ACCOUNTING STANDARDS BOARD, ASSETS AND LIABILITIES ARE ESTABLISHED FOR UNCERTAIN TAX POSITIONS TAKEN OR POSITIONS EXPECTED TO BE TAKEN IN INCOME TAX RETURNS WHEN SUCH POSITIONS ARE JUDGED TO NOT MEET THE "MORE-LIKELY-THAN-NOT" THRESHOLD, BASED UPON THE TECHNICAL MERITS OF THE POSITION. ESTIMATED INTEREST AND PENALTIES, IF APPLICABLE, RELATED TO UNCERTAIN TAX POSITIONS ARE INCLUDED AS A COMPONENT OF INCOME TAX EXPENSE. THE SYSTEM HAS EVALUATED THE POSITION TAKEN ON ITS FILED TAX RETURNS. THE SYSTEM HAS CONCLUDED NO UNCERTAIN INCOME TAX POSITIONS EXIST AT DECEMBER 31, 2016. CENTRAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENT IN FUNDS DOMICILED IN FOREIGN JURISDICTIONS 16978879 0 0 0 0 0 0 16978879 0 16978879 1 0 1 0 0 0 SCHEDULE F, PART IV, LINE 3: THE ORGANIZATION DID NOT HAVE AN OWNERSHIP INTEREST IN ANY FOREIGN CORPORATION THAT IS GREATER THAN THE 10% FILING THRESHOLD. ACCORDINGLY, IRS FORM(S) 5471 IS NOT REQUIRED TO BE FILED. 0 0 0 0 0 0 0 0 0 JOHN AHLE TREASURER/SECRETARY 0 434470 0 0 0 303793 0 10600 0 25419 0 774282 0 300000 CAROLYN KASABIAN TRUSTEE THRU 5/16 0 262121 0 0 0 0 0 2627 0 9801 0 274549 0 0 RICHARD J PLAMONDON VICE PRESIDENT 0 323831 0 0 0 2921 0 7268 0 25160 0 359180 0 0 SCHEDULE J, PART II, COLUMN F: JOHN AHLE, TREASURER, WAS A PARTICIPANT IN A DEFERRED COMPENSATION PLAN SPONSORED BY COVENANT HEALTH, INC. FROM 2011 THROUGH 2015, ALL OF WHICH WAS REPORTED ON PRIOR FORMS 990. THE $300,000 AMOUNT PAID IN 2016 IS REQUIRED TO BE REPORTED IN ITS ENTIRETY AGAIN ON SCHEDULE J, IN COLUMN F AND AS PART OF THE COMPENSATION REPORTED IN COLUMN B (III) OF THE 2016 FORM 990. FORM 990, PART VI, SECTION A, LINE 3 THE BOARD OF TRUSTEES DELEGATED MANAGEMENT DUTIES TO CARDINAL INVESTMENT MANAGEMENT, INC. (EIN 04-3391257). FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS PRESENTED TO, AND REVIEWED BY, THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE MONITORING AND ENFORCEMENT OF COMPLIANCE WITH THE POLICY IS COMPLETED AT THE INDIVIDUAL BOARD LEVELS OF THE ENTITIES THAT ARE SHAREHOLDERS OF PROVIDENTIA PRIMA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: NET TRANSFER TO AFFILIATES -13,947,926. COVENANT HEALTH INC 100 AMES POND DRIVE TEWKSBURY MA 01876 222484505 MANAGEMENT AND HEALTH RESOURCE ORGANIZATION MA 501(C)(3) LINE 10 N/A 0 ST MARY'S HEALTH SYSTEM PO BOX 7291 LEWISTON ME 04243 222504349 PARENT COMPANY ME 501(C)(3) LINE 10 COVENANT HEALTH 0 FANNY ALLEN CORPORATION 790 COLLEGE PARKWAY COLCHESTER VT 05446 222495808 HEALTH CARE SERVICES VT 501(C)(3) LINE 12A, I COVENANT HEALTH 0 CHS WALTHAM 66 NEWTON STREET WALTHAM MA 02453 043333609 SKILLED NURSING FACILITY MA 501(C)(3) LINE 10 COVENANT HEALTH 0 ST JOSEPH HOSPITAL 172 KINSLEY ST NASHUA NH 03061 020222215 ACUTE CARE HOSPITAL NH 501(C)(3) LINE 3 COVENANT HEALTH 0 YOUVILLE HOSPITAL 100 AMES POND DRIVE TEWKSBURY MA 01876 023239563 FORMER REHAB HOSPITAL MA 501(C)(3) LINE 3 COVENANT HEALTH 0 YOUVILLE PLACE 10 PELHAM RD LEXINGTON MA 02421 043297834 ASSISTED LIVING FACILITY MA 501(C)(3) LINE 10 COVENANT HEALTH 0 ST ANDRE SKILLED NURSING AND REHAB FACILITY 407 POOL ST BIDDEFORD ME 04005 010342399 SKILLED NURSING FACILITY ME 501(C)(3) LINE 10 COVENANT HEALTH 0 MI NURSING RESTORATIVE CENTER 172 LAWRENCE ST LAWRENCE MA 01841 042104851 SKILLED NURSING FACILITY MA 501(C)(3) LINE 10 COVENANT HEALTH 0 ST MARY'S VILLA NURSING HOME 675 ST MARYS VILLA ROAD MOSCOW PA 18444 232057177 SKILLED NURSING FACILITY PA 501(C)(3) LINE 10 COVENANT HEALTH 0 MI MANAGEMENT INC 172 LAWRENCE ST LAWRENCE MA 01841 042857794 SKILLED NURSING FACILITY MA 501(C)(3) LINE 10 COVENANT HEALTH 0 MI ADULT DAY HEALTH CENTER 172 LAWRENCE ST LAWRENCE MA 01841 042921888 SKILLED NURSING FACILITY MA 501(C)(3) LINE 10 COVENANT HEALTH 0 MI TRANSPORTATION 172 LAWRENCE ST LAWRENCE MA 01841 042921889 SKILLED NURSING FACILITY MA 501(C)(3) LINE 10 COVENANT HEALTH 0 YOUVILLE HOUSE 1575 CAMBRIDGE ST CAMBRIDGE MA 02138 043239593 ASSISTED LIVING FACILITY MA 501(C)(3) LINE 10 COVENANT HEALTH 0 YOUVILLE LIFECARE 100 AMES POND DRIVE TEWKSBURY MA 01876 042103582 MANAGEMENT SERVICES MA 501(C)(3) LINE 12A, I COVENANT HEALTH 0 ST MARY'S D'YOUVILLE PAVILION PO BOX 7291 LEWISTON ME 04243 010211558 NURSING HOME ME 501(C)(3) LINE 10 ST MARY'S HEALTH SYSTEM 0 ST JOSEPH HOSPITAL 360 BROADWAY BANGOR ME 04402 010212435 HOSPITAL ME 501(C)(3) LINE 1 ST JOSEPH HEALTHCARE FOUNDATION 0 ST JOSEPH AMBULATORY CAREINC 360 BROADWAY BANGOR ME 04402 222480373 PHYSICIAN PRACTICE ME 501(C)(3) LINE 3 ST JOSEPH HEALTHCARE FOUNDATION 0 COMMUNITY CLINICAL SERVICES PO BOX 7291 LEWISTON ME 04243 010409788 PHYSICIAN PRACTICE ME 501(C)(3) LINE 3 ST MARY'S HEALTH SYSTEM 0 ST MARY'S REGIONAL MEDICAL CTR PO BOX 7291 LEWISTON ME 04243 010211551 HOSPITAL ME 501(C)(3) LINE 3 ST MARY'S HEALTH SYSTEM 0 MOUNT ST RITA HEALTH CENTRE 15 SUMNER BROWN ROAD CUMBERLAND RI 02864 050342330 SKILLED NURSING FACILITY RI 501(C)(3) LINE 10 COVENANT HEALTH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1