Heng Fai Ambrose Chan - Jun 21, 2021 Form 4 Insider Report for DOCUMENT SECURITY SYSTEMS INC (DSS)

Role
Director, 10%+ Owner
Signature
/s/ Heng Fai Ambrose Chan
Stock symbol
DSS
Transactions as of
Jun 21, 2021
Transactions value $
$0
Form type
4
Date filed
6/23/2021, 09:41 PM
Previous filing
Jun 17, 2021
Next filing
Jul 20, 2021

Transactions Table

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Ownership Footnotes
transaction DSS Common Stock Conversion of derivative security +1.12M +12.56% 10M Jun 21, 2021 See footnote F1, F2, F3, F4

Derivative Securities (e.g., puts, calls, warrants, options, convertible securities)

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Underlying Class Amount Exercise Price Ownership Footnotes
transaction DSS Series A Convertible Preferred Stock Conversion of derivative security -7.26K -100% 0 Jun 21, 2021 Common Stock 1.12M See footnote F1, F2, F4
* An asterisk sign (*) next to the price indicates that the price is likely invalid.

Explanation of Responses:

Id Content
F1 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").
F2 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.
F3 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.
F4 These securities were owned directly by GBM. Mr. Chan has dispositive control over the securities of the Issuer owned by GBM.