- Initial Statement of Beneficial Ownership (3)
15 Januar 2010 - 9:15PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
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3235-0104
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February 28, 2011
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Milbrath David E.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
4/28/2009
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3. Issuer Name
and
Ticker or Trading Symbol
AMERICAN DENTAL PARTNERS INC [ADPI]
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(Last)
(First)
(Middle)
4753 HUMBOLDT AVE. SOUTH
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Street)
MINNEAPOLIS, MN 55419
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. 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 I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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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
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0
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D
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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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 of Derivative Security: 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
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Expiration Date
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Title
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Amount or Number of Shares
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Stock Option (right to buy)
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9/25/2008
(1)
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9/25/2017
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Common Stock
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20000
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$26.02
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D
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Stock Option (right to buy)
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2/22/2009
(2)
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2/22/2018
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Common Stock
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1500
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$9.58
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D
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Stock Option (right to buy)
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2/24/2010
(3)
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2/24/2019
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Common Stock
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7000
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$6.53
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D
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Explanation of Responses:
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(
1)
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The option was granted on September 25, 2007 and vests in four equal annual installments beginning on the first anniversary of the date of grant.
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(
2)
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The option was granted on February 22, 2008 and vests in four equal annual installments beginning on the first anniversary of the date of grant.
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(
3)
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The option was granted on February 24, 2009 and vests in four equal annual installments beginning on the first anniversary of the date of grant.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Milbrath David E.
4753 HUMBOLDT AVE. SOUTH
MINNEAPOLIS, MN 55419
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X
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Signatures
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Mark W. Vargo, Attorney-in-Fact and Agent
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1/15/2010
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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 control number.
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