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