Statement of Changes in Beneficial Ownership (4)

Date : 02/21/2020 @ 6:34PM
Source : Edgar (US Regulatory)
Stock : Document Security Systems Inc New (DSS)
Quote : 0.27  0.043 (18.94%) @ 12:00AM
After Hours
Last Trade
Last $ 0.24 ▼ -0.03 (-12.22%)

Statement of Changes in Beneficial Ownership (4)

FORM 4 [ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).         
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
                                                                                  
OMB APPROVAL
OMB Number: 3235-0287
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
                      

1. Name and Address of Reporting Person *

Chan Heng Fai Ambrose
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                    __X__ 10% Owner
_____ Officer (give title below)    _____ Other (specify below)
(Last)          (First)          (Middle)

C/O DOCUMENT SECURITY SYSTEMS, INC., 200 CANAL VIEW BLVD., SUITE 300
3. Date of Earliest Transaction (MM/DD/YYYY)

2/18/2020
(Street)

ROCHESTER, NY 14623
(City)        (State)        (Zip)
4. If Amendment, Date Original Filed (MM/DD/YYYY)

 
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. Trans. Date 2A. Deemed Execution Date, if any 3. Trans. Code
(Instr. 8)
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 2/18/2020  A  349917 A$0 (1)2427599 D  
Common Stock         6446428 I See Footnote (2)
Common Stock         1786531 I See Footnote (3)
Common Stock         500000 I See Footnote (4)
Common Stock         683000 I See Footnote (5)

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivate Security
(Instr. 3)
2. Conversion or Exercise Price of Derivative Security3. Trans. Date3A. Deemed Execution Date, if any4. Trans. Code
(Instr. 8)
5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
6. Date Exercisable and Expiration Date7. 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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)11. Nature of Indirect Beneficial Ownership (Instr. 4)
CodeV(A)(D)Date ExercisableExpiration DateTitleAmount or Number of Shares

Explanation of Responses:
(1) Represents a restricted stock grant awarded to the Reporting Person by the Issuer pursuant to the Executive Employment Agreement between the Issuer and the Reporting Person and the Issuer's 2020 Equity Incentive Plan, in consideration for the Reporting Person's services as Executive Chairman of the Issuer and Executive Chairman and Chief Executive Officer of the Issuer's subsidiary.
(2) Held by LiquidValue Development Pte Ltd., of which Reporting Person is the owner. The Reporting Person has dispositive control over these securities.
(3) Held by Heng Fai Holdings Limited, of which Reporting Person is the owner. The Reporting Person has dispositive control over these securities.
(4) 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.
(5) 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

Reporting Owners
Reporting Owner Name / Address
Relationships
Director10% OwnerOfficerOther
Chan Heng Fai Ambrose
C/O DOCUMENT SECURITY SYSTEMS, INC.
200 CANAL VIEW BLVD., SUITE 300
ROCHESTER, NY 14623
XX


Signatures
/s/ Chan Heng Fai Ambrose2/21/2020
**Signature of Reporting PersonDate

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