0001493152-17-010616.txt : 20170914
0001493152-17-010616.hdr.sgml : 20170914
20170914164520
ACCESSION NUMBER: 0001493152-17-010616
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20170912
FILED AS OF DATE: 20170914
DATE AS OF CHANGE: 20170914
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: 171086074
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
2017-09-12
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
1
0
Common Stock
2017-09-12
4
F
0
200000
0.75
A
500000
I
See Footnote
Common Stock
2017-09-12
4
J
0
683000
A
683000
I
See Footnote
Common Stock
800000
I
See Footnote
Common Stock
2612
D
Warrant to Purchase Common Stock
0.75
2017-09-12
4
F
0
200000
0.75
A
2016-12-29
2019-12-29
Common Stock
200000
0
I
See Footnote
Warrant to Purchase Common Stock
1.00
2017-09-08
2022-09-08
Common Stock
160000
160000
I
See Footnote
Held by BMI Capital Partners International Limited., of which the Reporting Person is a director. The Reporting Person has dispositive control over these securities.
Held by Hengfai Business Develoment Pte Ltd., of which the Reporting Person is the Chief Executive Officer and the owner. The Reporting Person has dispositive control over these securities.
Held by Heng Fai Holdings Limited, of which the Reporting Person is an Officer and the owner. The Reporting Person has dispositive control over these securities.
As consideration for the shares of the Issuer acquired on 09/12/2017 and that were valued at $0.71 per share, Hengfai Business Develoment Pte Ltd. exchanged securities of an entity listed on the Singapore Exchange Limited.
/s/ Heng Fai Ambrose Chan
2017-09-14