0001493152-21-015139.txt : 20210623 0001493152-21-015139.hdr.sgml : 20210623 20210623214106 ACCESSION NUMBER: 0001493152-21-015139 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210621 FILED AS OF DATE: 20210623 DATE AS OF CHANGE: 20210623 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: 211040418 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: 211040417 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 2021-06-21 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 2021-06-21 4 C 0 1120170 A 10036164 I See footnote Series A Convertible Preferred Stock 2021-06-21 4 C 0 7259 D Common Stock 1120170 0 I See footnote Global BioMedical Pte. Ltd. ("GBM") has converted 7,259 shares of Series A Convertible Preferred Stock into 1,120,170 shares of the common stock, par value $0.02 per share (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. Following the conversion of 7,259 shares of Series A Convertible Preferred Stock, GBM does not own any shares of Series A Convertible Preferred Stock. Mr. Chan has dispositive control over the securities owned by GBM. The beneficial ownership of the Reporting Person includes 10,036,164 shares of Common Stock, consisting of (a) 1,614,552 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) 7,716,004 shares of Common Stock held by Global Biomedical Pte. Ltd. These securities were owned directly by GBM. Mr. Chan has dispositive control over the securities of the Issuer owned by GBM. /s/ Heng Fai Ambrose Chan 2021-06-23 /s/ Global BioMedical Pte. Ltd by Heng Fai Ambrose Chan 2021-06-23