DSS (DSS) Form 4 DOCUMENT SECURITY SYSTEMS / Heng Fai Ambrose Chan ownership change

SEC Form 4

FORM 4

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940

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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

1. Name and Address of Reporting Person^*

Chan Heng Fai Ambrose

(Last) (First) (Middle)

C/O DOCUMENT SECURITY SYSTEMS, INC.

200 CANAL VIEW BLVD., SUITE 300

(Street)

ROCHESTER NY 14623

(City) (State) (Zip)

2. Issuer Name and Ticker or Trading Symbol
DOCUMENT SECURITY SYSTEMS INC [ DSS ]

5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	X	10% Owner
	Officer (give title below)		Other (specify below)

3. Date of Earliest Transaction (Month/Day/Year)
08/21/2020

4. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3)	2. Transaction Date (Month/Day/Year)	2A. Deemed Execution Date, if any (Month/Day/Year)	3. Transaction Code (Instr. 8)		4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5)			5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)	6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)
			Code	V	Amount	(A) or (D)	Price
Common Stock	08/21/2020		J		483,334(1)	A	$6.48(1)	483,334	I	See Footnote(1)
Common Stock								80,920	D
Common Stock								585,251	I	See Footnote(2)
Common Stock								59,551	I	See Footnote(3)
Common Stock								22,767	I	See Footnote(4)
Common Stock								16,667	I	See Footnote(5)

Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3)	2. Conversion or Exercise Price of Derivative Security	3. Transaction Date (Month/Day/Year)	3A. Deemed Execution Date, if any (Month/Day/Year)	4. Transaction Code (Instr. 8)		5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)		6. Date Exercisable and Expiration Date (Month/Day/Year)		7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4)		8. Price of Derivative Security (Instr. 5)	9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)	10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
				Code	V	(A)	(D)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares
Series A Convertible Preferred Stock	$6.48(6)	08/21/2020		J		46,868		(6)	(6)	Common Stock	7,232,716(6)	(6)	46,868	I	See Footnote(6)

Explanation of Responses:

1. On August 21, 2020, Document Security Systems, Inc., a New York corporation (the "Issuer") closed on a share exchange agreement (the "Exchange Agreement") by and among the Issuer, DSS BioHealth Security, Inc., Singapore eDevelopment Ltd. ("SeD"), an entity controlled by the Reporting Person, and Global Biomedical Pte Ltd. ("GBM"), a wholly-owned subsidiary of SeD. Pursuant to the Exchange Agreement, GBM received 483,334 shares of the Issuer's common stock at a per share cost basis of $6.48 per share. The Reporting Person has dispositive control over these securities.

2. Held by LiquidValue Development Pte Ltd., of which Reporting Person is the owner. The Reporting Person has dispositive control over these securities.

3. Held by Heng Fai Holdings Limited, of which Reporting Person is the owner. The Reporting Person has dispositive control over these securities.

4. Held by Hengfai Business Development Pte Ltd, of which Reporting Person is the Chief Executive Officer and Owner. The Reporting Person has dispositive control over these securities.

5. Held by BMI Capital Partners International Limited, of which the Reporting Person is an owner and director. The Reporting Person has dispositive control over these securities.

6. In connection with the Exchange Agreement, GBM received 46,868 newly issued shares of the Issuer's Series A Convertible Preferred Stock ("Series A Preferred Stock") with a stated value of $46,868,000, or $1,000 per share. The Series A Preferred Stock is convertible into shares of common stock of DSS, at an initial conversion price of $6.48 per share, subject to a 19.9% beneficial ownership conversion limitation ("Blocker") based on the total issued and outstanding shares of common stock of the Issuer beneficially owned by GBM. As of August 21, 2020, there were 5,115,179 shares of the Issuer's common stock issued and outstanding, and therefore, as a result of the Blocker, GBM is currently only able to convert the number of Series A Preferred Stock equal to approximately 673,904 shares of the Issuer's common stock, or approximately 4,366 shares of Series A Preferred Stock. The Reporting Person has dispositive control over these securities.

	/s/ Heng Fai Ambrose Chan	08/25/2020
	** Signature of Reporting Person	Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
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