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