SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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
OMB APPROVAL
OMB Number: 3235-0287
Expires: December 31, 2014
Estimated average burden
hours per response: 0.5
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
Chan Heng Fai Ambrose
(Last) (First) (Middle)
C/O DOCUMENT SECURITY SYSTEMS, INC.
200 CANAL VIEW BLVD., SUITE 300
(Street)
ROCHESTER NY 14623
(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
DOCUMENT SECURITY SYSTEMS INC [ DSS ] 5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
03/25/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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.
4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 1,786,531 I See Footnote(1)
Common Stock 500,000 I See Footnote(2)
Common Stock 683,000 I See Footnote(3)
Common Stock 2,912 D
Common Stock 03/25/2019 C 446,428 A $1.12 446,428 I See Footnote(4)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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. 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)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Convertible Promissory Note $1.12 03/25/2019 C 446,428 02/18/2019 02/18/2020 Common 446,428 (4) 0 I See Footnote(4)
Explanation of Responses:
1. Held by Heng Fai Holdings Limited of which Reporting Person is the owner. The Reporting Person has dispositive control over these securities.
2. Held by BMI Capital Partners International Limited of which the Reporting Person is an owner and director. The Reporting Person has dispositive control over these securities.
3. Held by Hengfai Business Development Pte Ltd of which Reporting Person is the Chief Executive Officer and Owner. The Reporting Person has dispositive control over these securities.
4. On March 25, 2019, a Convertible Promissory Note in the amount of $500,000 was converted into 446,428 shares of the common stock of Document Security Systems, Inc. These shares are held by LiquidValue Development Pte Ltd, of which the Reporting Person is the owner and a director. The Reporting Person has dispositive control over these shares.
/s/ Heng Fai Ambrose Chan 03/26/2019
** Signature of Reporting Person Date
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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
OMB APPROVAL
OMB Number: 3235-0287
Expires: December 31, 2014
Estimated average burden
hours per response: 0.5
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
Chan Heng Fai Ambrose
(Last) (First) (Middle)
C/O DOCUMENT SECURITY SYSTEMS, INC.
200 CANAL VIEW BLVD., SUITE 300
(Street)
ROCHESTER NY 14623
(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
DOCUMENT SECURITY SYSTEMS INC [ DSS ] 5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
03/25/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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.
4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4) Code V Amount (A) or (D) Price
Common Stock 1,786,531 I See Footnote(1)
Common Stock 500,000 I See Footnote(2)
Common Stock 683,000 I See Footnote(3)
Common Stock 2,912 D
Common Stock 03/25/2019 C 446,428 A $1.12 446,428 I See Footnote(4)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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.
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) Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Convertible Promissory Note $1.12 03/25/2019 C 446,428 02/18/2019 02/18/2020 Common 446,428 (4) 0 I See Footnote(4)
Explanation of Responses:
1. Held by Heng Fai Holdings Limited of which Reporting Person is the owner. The Reporting Person has dispositive control over these securities.
2. Held by BMI Capital Partners International Limited of which the Reporting Person is an owner and director. The Reporting Person has dispositive control over these securities.
3. Held by Hengfai Business Development Pte Ltd of which Reporting Person is the Chief Executive Officer and Owner. The Reporting Person has dispositive control over these securities.
4. On March 25, 2019, a Convertible Promissory Note in the amount of $500,000 was converted into 446,428 shares of the common stock of Document Security Systems, Inc. These shares are held by LiquidValue Development Pte Ltd, of which the Reporting Person is the owner and a director. The Reporting Person has dispositive control over these shares.
/s/ Heng Fai Ambrose Chan 03/26/2019
** Signature of Reporting Person Date
