0001493152-21-014712.txt : 20210617 0001493152-21-014712.hdr.sgml : 20210617 20210617184445 ACCESSION NUMBER: 0001493152-21-014712 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210615 FILED AS OF DATE: 20210617 DATE AS OF CHANGE: 20210617 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: 211026375 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: 6 FRAMARK DR. CITY: VICTOR STATE: NY ZIP: 14564 BUSINESS PHONE: 585 232 1500 MAIL ADDRESS: STREET 1: 6 FRAMARK DR. CITY: VICTOR STATE: NY ZIP: 14564 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 ownership.xml X0306 4 2021-06-15 0 0000771999 DOCUMENT SECURITY SYSTEMS INC DSS 0001261725 Chan Heng Fai Ambrose C/O DOCUMENT SECURITY SYSTEMS, INC. 6 FRAMARK DRIVE VICTOR NY 14564 1 0 1 0 Common Stock 2021-06-15 4 P 0 115960 1.77 A 7507972 D Common Stock 2021-06-15 4 P 0 884040 1.69 A 8392012 D Common Stock 2021-06-16 4 P 0 555000 1.70 A 8947012 D The beneficial ownership of the Reporting Person includes, in addition to those purchases described herein, 7,392,012 shares of common stock, par value $0.02 per share, of Document Security Systems, Inc. ("Common Stock"), consisting of (a) 59,552 shares of Common Stock held by Heng Fai Holdings Limited; (b) 16,667 shares of Common Stock held by BMI Capital Partners International Limited; (c) 474,060 shares of Common Stock held by the Reporting Person; (d) 214,881 shares of Common Stock held by LiquidValue Development Pte Ltd.; and (e) (i) 6,595,834 shares of Common Stock and (ii) 31,018 shares of Common Stock that could be obtained upon the conversion of shares of Series A Convertible Preferred Stock, par value $.02 per share, beneficially owned by the Reporting Person, held by Global Biomedical Pte. Ltd. /s/ Heng Fai Ambrose Chan 2021-06-17