0001493152-17-010498.txt : 20170912
0001493152-17-010498.hdr.sgml : 20170912
20170912170014
ACCESSION NUMBER: 0001493152-17-010498
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20170908
FILED AS OF DATE: 20170912
DATE AS OF CHANGE: 20170912
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Chan Heng Fai Ambrose
CENTRAL INDEX KEY: 0001261725
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-32146
FILM NUMBER: 171081637
MAIL ADDRESS:
STREET 1: 2601 INSLAND PLACE TOWER
STREET 2: 510 KINGS RD N POINT
CITY: HONG KONG
STATE: K3
ZIP: 999999999
FORMER NAME:
FORMER CONFORMED NAME: CHAN FAI
DATE OF NAME CHANGE: 20030828
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: DOCUMENT SECURITY SYSTEMS INC
CENTRAL INDEX KEY: 0000771999
STANDARD INDUSTRIAL CLASSIFICATION: PAPERBOARD CONTAINERS & BOXES [2650]
IRS NUMBER: 161229730
STATE OF INCORPORATION: NY
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 200 CANAL VIEW BOULEVARD
STREET 2: SUITE 300
CITY: ROCHESTER
STATE: NY
ZIP: 14623
BUSINESS PHONE: 585 232 1500
MAIL ADDRESS:
STREET 1: 200 CANAL VIEW BOULEVARD
STREET 2: SUITE 300
CITY: ROCHESTER
STATE: NY
ZIP: 14623
FORMER COMPANY:
FORMER CONFORMED NAME: NEW SKY COMMUNICATIONS INC
DATE OF NAME CHANGE: 19920703
FORMER COMPANY:
FORMER CONFORMED NAME: THOROUGHBREDS USA INC
DATE OF NAME CHANGE: 19861118
4
1
form4.xml
X0306
4
2017-09-08
0
0000771999
DOCUMENT SECURITY SYSTEMS INC
DSS
0001261725
Chan Heng Fai Ambrose
C/O DOCUMENT SECURITY SYSTEMS, INC.
200 CANAL VIEW BLVD., SUITE 300
ROCHESTER
NY
14623
1
0
0
0
Common Stock
2017-09-08
4
P
0
800000
0.75
A
1100000
I
See Footnote
Common Stock
2611
D
Warrants
1.00
2017-09-08
4
P
0
160000
0
A
2017-09-08
2022-09-08
Common Stock
160000
160000
I
See Footnote
Warrants
1.00
2016-12-29
2019-12-29
Common Stock
200000
200000
I
See Footnote
The Reporting Person is a director of BMI Capital Partners International Ltd. ("BMI Capital"), which owns 300,000 shares of the Issuer's common stock purchased on 12/29/16. The Reporting Person is also the CEO and majority shareholder of Heng Fai Holdings Limited ("HF Holdings"), which owns the 800,000 shares of Issuer's common stock purchased on 9/8/17. Reporting Person has dispositive control over all of these shares.
BMI capital owns the previously issued warrants to purchase 200,000 shares of the Issuer's common stock. HF Holdings owns the warrants to purchase 160,000 shares of Issuer's common stock. Reporting Person has dispositive control over all of these warrants.
The price of the warrants is included in the price of the shares reported in Table I.
/s/ Heng Fai Ambrose Chan
2017-09-12