Statement of Changes in Beneficial Ownership (4)
February 21 2020 - 1:34PM
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
*
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 300 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
2/18/2020 |
(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)
_X
_ Form filed by One Reporting Person
___ 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 | 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)
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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 |
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
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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 300 ROCHESTER, NY 14623 | X | X |
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Signatures
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/s/ Chan Heng Fai Ambrose | | 2/21/2020 |
**Signature of Reporting Person | Date |
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