0001493152-21-013109.txt : 20210527 0001493152-21-013109.hdr.sgml : 20210527 20210527200356 ACCESSION NUMBER: 0001493152-21-013109 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210526 FILED AS OF DATE: 20210527 DATE AS OF CHANGE: 20210527 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: 21975303 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 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Global BioMedical Pte. Ltd. CENTRAL INDEX KEY: 0001823066 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-32146 FILM NUMBER: 21975302 BUSINESS ADDRESS: BUSINESS PHONE: 3019713940 MAIL ADDRESS: STREET 1: 7 TEMASEK BOULEVARD #29-01B STREET 2: SUNTEC TOWER ONE CITY: SINGAPORE STATE: U0 ZIP: 038987 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 2021-05-26 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 0001823066 Global BioMedical Pte. Ltd. 7 TEMASEK BOULEVARD #29-01B, SUNTEC TOWER ONE SINGAPORE U0 14564 SINGAPORE 0 0 1 0 Common Stock 2021-05-26 4 C 0 5450000 A 6595834 I See footnote Series A Convertible Preferred Stock 2021-05-26 4 C 0 35316 D Common Stock 5450000 7259 I See footnote Global BioMedical Pte. Ltd. ("GBM") has converted 35,316 shares of Series A Convertible Preferred Stock into 5,450,000 shares of the common stock of Document Security Systems, Inc. (the "Issuer"). The Series A Convertible Preferred Stock of the Issuer has a stated value of $1,000 per share and may be converted into shares of the common stock of the Issuer at a conversion price of $6.48 per share, subject to a 19.99% beneficial ownership conversion limitation (the "Blocker") based on the total issued and outstanding shares of common stock of the Issuer beneficially owned by GBM. There are currently 33,120,125 shares of the Issuer's common stock issued and outstanding, and therefore, as a result of the Blocker, GBM is currently able to convert an additional 201 shares of Series A Preferred Stock, equal to 31,018 shares of the Issuer's common stock. Mr. Chan has dispositive control over the securities owned by GBM. These securities are owned directly by GBM. Mr. Chan has dispositive control over the common stock and Series A Convertible Preferred Stock of the Issuer owned by GBM. /s/ Heng Fai Ambrose Chan 2021-05-27 /s/ Global BioMedical Pte. Ltd by Heng Fai Ambrose Chan 2021-05-27