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FORM 4
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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OMB APPROVAL
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| Estimated average burden hours per response... | 0.5 |
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(Print or Type Responses)
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1. Name and Address of Reporting Person *
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| Chan Heng Fai Ambrose |
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2. Issuer Name and Ticker or Trading Symbol
DOCUMENT SECURITY SYSTEMS INC [DSS]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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__X__ Director
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__X__ 10% Owner
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_____ Officer (give title below)
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_____ Other (specify below)
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C/O DOCUMENT SECURITY SYSTEMS, INC., 200 CANAL VIEW BLVD., SUITE 300 |
3. Date of Earliest Transaction (Month/Day/Year)
02/24/2020 |
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ROCHESTER, NY 14623 |
4. If Amendment, Date Original Filed
(Month/Day/Year)
02/27/2020 |
6. Individual or Joint/Group Filing
(Check Applicable Line)
_X_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Transaction Date (Month/Day/Year)
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2A. Deemed Execution Date, if any (Month/Day/Year)
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3. Transaction Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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| Common Stock | 02/24/2020 |
| A |
| 11,111,112 (1) | A |
$0.18 (2) | 13,538,711 | D |
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| Common Stock |
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| 6,446,428 | I | See Footnote (3) |
| Common Stock |
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| 1,786,531 | I | See Footnote (4) |
| Common Stock |
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| 500,000 | I | See Footnote (5) |
| Common Stock |
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| 683,000 | I | See Footnote (6) |
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| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 1474 (9-02) |
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)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date (Month/Day/Year)
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3A. Deemed Execution Date, if any (Month/Day/Year)
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4. Transaction Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4, and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year)
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7. Title and Amount of Underlying Securities
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Reporting Owners
| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
Chan Heng Fai Ambrose
C/O DOCUMENT SECURITY SYSTEMS, INC.
200 CANAL VIEW BLVD., SUITE 300
ROCHESTER, NY 14623 |
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X
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Signatures
| /s/ Chan Heng Fai Ambrose | |
03/05/2020 |
| **Signature of Reporting Person | Date |
Explanation of Responses:
| * | 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). |
| (1) | The original Form 4 filed on February 27, 2020 is amended by this Form 4 amendment to correctly reflect the reporting person's ownership of Common Stock. No other changes have been made to the original Form 4. |
| (2) | On February 24, 2020, the Reporting Persons purchased from the Issuer 11,111,112 shares of the Issuer's Common Stock, in an underwritten public offering, in consideration for $2,000,000. |
| (3) | Held by LiquidValue Development Pte Ltd., of which Reporting Person is the owner. The Reporting Person has dispositive control over these securities. |
| (4) | Held by Heng Fai Holdings Limited, of which Reporting Person is the 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) | 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 |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number.
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