Ve C129 73 oe curan sans [asa FORM D cscanm AST consason x FORM D ititimmmiiiacilin, F Rorce onsen or ecuares WACO PURSUANT TO REGULATION D, 06043802 SECTION 4(6), AND/OR UNIFORM LIMITED OFFERING EXEMPTION i \ ‘Name of Offering ‘Co check this is an amendment and name has changed, and indicate change) 1 Commons Seis ASera buena reenesSunaftearana nar ee SI Filing Under (Check Dore ar opay LI Rae 308 Tr Rate 05 BH Ra TrseitayQey CIULE Tyg Fig Bl New Ply Aner Ly ‘BASIC IDENTIFICATION DATA Z ey (sna er pt “Name ofissuer (Cl check thie an amendment and name has Sanged, nd indicate ange) oh ry Heartland Dental Care, Ine. Pr <> aay Essa OTS a a “is {200 Network Cente Driv Egham 6401 ee tees Tas of iia aes Opa — Warr an ie Ci Ss FCO) Toke Naar cag As CO) (iitre om Executive fess) “Bre Daainion oT Bsns [A dental practice management company that develop, manage and consolidates dental practices primary inthe Midwesterm and Florida market “Type of Busnes Oration corporation Ctinitea panne sready formed exter (tease speci: business rs _iimied pares obe formed = Mond Year -Acun o¢Exinted Dat of incorporation or Orgnization: 0206 Barctst Ch stiated Surttion of Incorporation or Organon: (Ete leter US, Postal Sevse abbreition for Ste: CN for Canada; FN for ber eign jursiion) DE ———— OC GENERAL INSTRUCTIONS 7 N\ Federal: Who Mut Fie- All eves making an ofering of eect in relanee onan exemption under Regulation D or Seton 4(6), 17 CFR 230501 et eq. or 1S Use 746) When To Fle A notice must be filed no ater tan 1S day afer theft sal of sects inthe ofering. A nti ie dame fed withthe US Secures and Exchange Commission (SEC) onthe eater ofthe dat it recived by the SEC at the sess giver below oi reeived a that dress er the de on which {edu onthe dle tas mailed by United States reper orcad mato the adress. Where To Fue: US. Sacwrties and Exchange Camission, 450 Fi Stet, NW. Washington, DC. 20888 Copies Required Five (3) copies of hie ntice ate Ted with he SEC, on of which must be manually signed Any copie not manly sgned mist be photozopes of ne marly signed coy or bear ped opted signe, Information Required: A new ling must conan ll information requested. Amendments ned nly rpon the name ofthe issuer and ofring, any changes ‘hero, he information egustedin Part C, and any material changes om he information previously supplied in Pats A and B. Part E andthe Appendix need note Bled wate SEC. Fig Fo: Theres no federal Hing seate ‘This notice shal bused indict reace on the Uniform Limited Offering Exemption (ULOE) for ses of secures in hase states that have adopted ULOE nd that have adopted hs frm. ser relying on ULOE mus lea separate notice withthe Secures Adminisoaar in each sale where sale re 0 be, oF ave been made. If state egies he payment of fee precoion athe lai forthe exemption, ae nthe pope rout hl company his form, ‘This moti stl be filed i the sppropte sates in accordance with ste law. The Appendix to the otc constitute pat ofthis ntce and must be compete “ATTENTION sult in a loss ofthe federal exemption. Conversely, failure f0 Mle the vallable state exemption unless such exemption is predicated on the fillg of & Failure to fle notice in the appropriate states wlll no appropriate ederal notice wil not result ina loss of federal notice 7 Persons wo respond fo the coleton af information comand SEC 197215405) {is frm are not reqlred to respond ones the form dlsplays = 19gs ‘arcenty valid OMB contol mmber‘A. BASIC IDENTIFICATION DATA sie he norton request TOE + Esch promoter ofthe ase, ifthe iar as been gained within the pS ear ‘+ Esch ene nner having the power to vot or ispase,o direc the vote or isposkian of, 10% or more ofa clas of equty seers ofthe 1+ Each executive ofa and reir of aporteieser and of eorporte reer and managing pres of parmersip sens snd Each genera and managing pare of pari sues (Check Box(e) at Appr) Promaer ) Benelcsl Owner Enecive OMicer (Dieu C] Cenenlanion Managing Par Fal Nase (Can ae Ray ‘Workman, Richard, DMD ‘sins or Reine Aan Naribr ad Sr is, Sate, Zip Cole) 1200 Network Centre Drive Effingham, IL 62401 (Check Boxes) tat Apply CJ omar C Beneficial Owner Exceutve Omer BY Decor] General andlor ‘Managing Parner Fal Name ast oan fain) Bauer, Patrick Tries or Rendsice Ales (Natibar and Sea, Cy, Sate, Zip Code) 1200 Network Cente Deve, Effinghany I. 62401 ‘Check Bowiytha Appi) Promaer C) BeveBcsl Omer Executve Offic G] Diecor Ol Genwrlandir Managing Parmer Fa Name (ast nae ft naa) Shack, John Business o Residnee Ales (Number and SURE Cig, Sa ip Code) 1200 Neovark Centre Drive Efioghar 162801 ‘Check Boxes) that Apply) Promaer () Beneisal nner‘) Execahe Otic ) Diecwr ( Genealandior Managing Parr Fu Name (astra Tania ‘Basins or Renee Aiea (Namib an Soe, Cig, Sa Zip Cale) Check Boxie) ar Apsy C] Pomacr C) BeweciolOwer Gl erecuiveomeer —L] Decor —_L] Gewratandor Managing Paoer Fal Namie Las eT RaW) "Busi or Resience AGH (Nabe and SHAN, Ci, Sale, Zip CO) ‘Check Boxe) tha Apple I Promter CE) Beneficial Omer Exeoutve Oise C) Decor _L Gereralandor ‘Managing Pastner Fall Nae (as wae Finda Basins or Reece Addies (Nariba nd Suet Cay, Sate ZipCode) ‘Check Box(e) hat Apply) Promeicr CI Beneficial Omer ExecuiveOmeer C] Decor) Gawralandior Managing Parner Fall Name (Lat name fat Wind) "Bunt or ReaiSence Adan Nunbr and See, Ci, Sate, Zip CO) (Check Boxiel that Apply] Promaer (C] BevefcialOwner — ExecuveOMfcer_C] Dinetor C] Grnealandor Managing Paoer Tal Nae (Lan rane We naa) asians Rescence Aiton Namba and Suet iy, Sate, Zip Cosy (sebianksbe or op and ue atonal opie ofthis set as cesar) roto'B. INFORMATION ABOUT OFFERING 1 Hasihe laser sold or does th issuer inte oslo nowacereded investors nis oeving? Yes Ne Arse ao in Append, Clu 2, fing der ULOE. 2 What heminimutn invesment that wil be aceped om ay invidu? 3. Doss the fering pert jot ownership of singe wi? Yes No 4 Ener te formation request fr ech person who has been a wil be i or give, ety ondiet, any commision ot "ir enumeration for soleaton of purchasers conection sith se of secure nthe fring person to bese fan asacsted person or agent of broker or dele registered wih the SEC andlor witha tate stats, list the name of the {rokerar dele. If more un five (3) persons tobe ised ar siecaed persons of cha broker or dealer, you may efor he infomation fr that broker or celeron a Was (Last are fs, inv aie or Reser Adies (Namib an Sua Ci ‘Sie ip CO Tome of Anocied Trak or Dslr ‘Slate in Whi Pon ited Has STIS Tani a SET PES (Cech "Al State” oceck individu Sates) Danses © @®eAee ea ea @ Qo @ & we = ir @ © @ Aaa BEE a AaB a aT Rae Las eT, nay an 6 Reais Aaa (Number and Sa, Ci, Sa Zip CO ‘Nas of Ano ote or Daler ‘Sir Wich Perso Lied Hn Sole o Its Sen Parana (CheckAll Sate or check indivi! Sates) CD atstes @ a a S @ OH ® 2 ® wi lag a88B SB 8 & Ful Name (as name Wt india) Tiss Redan AES (Namib md SRR, CW, See, Zip CO) Tae of Ariat Braker Dele ‘Saker n Wiveh Peon td as Sood or Tend 0 Sole Paha (Check “Al States or check individual Stas). @ ea = = iD] & Be Bee ii] J (5x HBEE (re ak shes, or opy and ean ope of hie ss a eeu) bers~'G. OFFERING PRICE, NUMBER OF INVESTORS, EXPENSES AND USE OF PROCEEDS Ener he agent fering pric of sevurtes saad in hie lfring and the al smoum sed a Enter" fhe answer shone” onze” ithe nation an enchangeeflerng check ths fos Cand ‘nde nthe colunne below the aroun of to secures offered fr exetange and sey exehangs “Types of Security Debs auiy : 1B common BI Prefered Conseil Securities (nung waras) Series A, Series Band Series Preferred Stock Parmer Ineress. ber Speci. 3 Tost Answer alin Appenx, Cola 3, i ling under ULOE. ‘The shares of Common Stock, Seis A, Sere Band Series C Prefered Stock were sued io nnection witha merger. However, cre i 0 absaate dollar amount that cane atribatd tothe Enter te number of scredd and non-accredited investors who have purchased secure in thi fering an the sgargate dlr amounts oftheir purchases. For oferings under Rule 80, insted nuanbe of persons \whoave purchased secures and he aggregate dela soit ofthe parchates on tne tt ines Ener "0" $Fangnerif "none" of 20 Accredited Investor e Nonacreied Investors “oul (fr ngs under Rue $05 on) -Arsier ao in Append, Clan ing under ULOE. {Cheng is for an offering wer Rte $08 o 50, enter the infomation requested for al secures sod by the isu, to date, in oflennge of the fpes inetd, in the twelve (12) moat pit 10 te Test sale of Secures itis fering Clas secunies by type ted in Pat C~ Question | TypeotOfring NOT APPLICABLE Rute S0s Regulation A Rute Soe : 4 Fumish a statement of al expenses connection wih the suance snd dsrbtion ofthe sous in is ffecng. Exclude amounts ans solely to enganiation expenses of he neuer The information may be vena subject to ftueeoningenies. Ith mau ofan expense et known, fish anette nd heck he Bo he eof the ema ‘Transfer Age's Fees - Priming ar Engraving Costs Lega Fees - Acouming Fees Engineering Fees : Sales Commissions specify ides fes separately) (Other Expense Went) _Flmansal Advisor Fee Tosa! ots Aepevate orterng Price s s Tye ot security Bacogeao Amount Already Sold 5 8 Dollar Atpount| Sold~ G. OFFERING PRICE, NUMBER OF INVESTORS, EXPENSES AND USE OF PROCEEDS mere dfence between the aggregate ofeig price given in espana o Fat C— Quetion 1 nol expences fume response to Pan C~ Question a. This deren ithe “adjusted gross procends tothe sur” * Nocash proceeds were received by the ser 8 : 5. net below te mount ofthe adjusted goss proceed tothe ser we or proposed to be ud foreach of {he purose shown the eat for any purpae nt know fai anette an heck he bo othe Ichotthe eimate‘The ttl fhe poy fated ust eal he djs gon raced fo he ue set {oh in spose to Pat C~ Question 4 above, Paymens 10 Offs, Direors ® Payments Atte ‘onter Saris and es Os. Os. Purchase of el ete Ds Os. Purchase, etl or leasing nd istallaon of machinery and equipment Os Os ‘Consoutionoasng of plant buléngs and fies Os os /Acquiton of oer bsinese luting the value of scares involved in this fering that may be used in exchange forthe assets or sear of ante issuer pursuant oa merger solute olla value canbe assigned tote shares sued by the Campany. Osos ose Repayment of indebtedness Bs. Os Working capita Os. Os. Otter pect Os eee ye Clare Totals Total Payers Listed (com tl ded) , FEDERAL SIGNATURE “The sue as duly caused iis note to be sane by the undersigned uly authorized peson, [this nate ls led une Rule $05, the ollwing sprue onstutes an undertaking bythe ser to fumsh he US, Series and Exchange Commision, upen writen request of its sa the ivoaratinfurished tyre tescerto ty nonaccreded investor print oprah ONG) af Rie S02 Tssuer (Print or Type) ‘Signature ~T Date Heartland Dental Care Ine | Jy 21, 2006 Saneot Sige ana TR) TEST ; Jo Slack Chief Fanci Oncor “ATTENTION Intentional misstatements or omssons of fact constitute federal criminal violations. (See 18 U.S.C. 1001) soto