Statement of Changes in Beneficial Ownership (4)
October 23 2020 - 5:56PM
Edgar (US Regulatory)
FORM 4
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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
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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
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1. Name and Address of Reporting Person
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Chan Heng Fai Ambrose |
2. Issuer Name and Ticker or Trading Symbol
DOCUMENT SECURITY SYSTEMS INC
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DSS
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director __X__ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
C/O DOCUMENT SECURITY SYSTEMS, INC., 200 CANAL VIEW BLVD., SUITE 104 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
10/16/2020 |
(Street)
ROCHESTER, NY 14623
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
___ Form filed by One Reporting Person
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X
_ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 10/16/2020 | | C(1) | | 662500 | A | (2) | 1145834 | I | See footnote (3) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. 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 Date | 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 of Derivative Security: 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 |
Series A Convertible Preferred Stock | (2) | 10/16/2020 | | C (1) | | | 4293 | (2) | (2) | Common Stock | 662500 | (2) | 42575 | I | See footnote (3) |
Explanation of Responses: |
(1) | Global BioMedical Pte. Ltd. ("GBM") has converted 4,293 shares of Series A Convertible Preferred Stock into 662,500 shares of the common stock of Document Security Systems, Inc. (the "Issuer"). |
(2) | The Series A Convertible Preferred Stock of the Issuer has a stated value of $1,000 per share and may be converted into shares of the common stock of the Issuer at a conversion price of $6.48 per share, subject to a 19.99% beneficial ownership conversion limitation (the "Blocker") based on the total issued and outstanding shares of common stock of the Issuer beneficially owned by GBM. There are currently 5,836,212 shares of the Issuer's common stock issued and outstanding, and therefore, as a result of the Blocker, GBM is currently able to convert an additional 168 shares of Series A Preferred Stock, equal to 25,925 shares of the Issuer's common stock. Mr. Chan has dispositive control over the securities owned by GBM. |
(3) | These securities are owned directly by GBM. Mr. Chan has dispositive control over the common stock and Series A Convertible Preferred Stock of the Issuer owned by GBM. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Chan Heng Fai Ambrose C/O DOCUMENT SECURITY SYSTEMS, INC. 200 CANAL VIEW BLVD., SUITE 104 ROCHESTER, NY 14623 | X | X |
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Global BioMedical Pte. Ltd. 7 TEMASEK BOULEVARD #29-01B, SUNTEC TOWER ONE SINGAPORE, U0 14564 |
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Signatures
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/s/ Heng Fai Ambrose Chan | | 10/23/2020 |
**Signature of Reporting Person | Date |
/s/ Global BioMedical Pte. Ltd., by Heng Fai Ambrose Chan | | 10/23/2020 |
**Signature of Reporting Person | Date |
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