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.
6 FRAMARK DRIVE

(Street)
VICTOR NY 14564

(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)
05/26/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X 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 05/26/2021 C(1) 5,450,000 A (2) 6,595,834 I See footnote(3)
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 (2) 05/26/2021 C(1) 35,316 (2) (2) Common Stock 5,450,000 (2) 7,259 I See footnote(3)
1. Name and Address of Reporting Person*
Chan Heng Fai Ambrose

(Last) (First) (Middle)
C/O DOCUMENT SECURITY SYSTEMS, INC.
6 FRAMARK DRIVE

(Street)
VICTOR NY 14564

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Global BioMedical Pte. Ltd.

(Last) (First) (Middle)
7 TEMASEK BOULEVARD #29-01B,
SUNTEC TOWER ONE

(Street)
SINGAPORE U0 14564

(City) (State) (Zip)
Explanation of Responses:
1. 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").
2. 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.
3. 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 05/27/2021
/s/ Global BioMedical Pte. Ltd by Heng Fai Ambrose Chan 05/27/2021
** 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).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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