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