Sec Form 4 Filing - Chan Heng Fai Ambrose @ DOCUMENT SECURITY SYSTEMS INC - 2017-09-08

Insider filing report for Changes in Beneficial Ownership
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FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
Chan Heng Fai Ambrose
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 _____ 10% Owner
_____ Officer (give title below) _____ Other (specify below)
(Last) (First) (Middle)
C/O DOCUMENT SECURITY SYSTEMS, INC., 200 CANAL VIEW BLVD., SUITE 300
3. Date of Earliest Transaction (MM/DD/YY)
09/08/2017
(Street)
ROCHESTER, NY14623
4. If Amendment, Date Original Filed (MM/DD/YY)
6. Individual or Joint/Group Filing (Check Applicable Line)
__ X __ Form filed by One Reporting Person
_____ Form filed by More than One Reporting Person
(City) (State) (Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 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 09/08/2017 P 800,000 A $ 0.75 1,100,000 I See Footnote ( 1 )
Common Stock 2,611 D
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 (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 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
(MM/DD/YY)
7. Title and Amount of Underlying Securities
(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 of Derivative Security: 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
Warrants $ 1 09/08/2017 P 160,000 09/08/2017 09/08/2022 Common Stock 160,000 $ 0 ( 3 ) 160,000 I See Footnote ( 2 )
Warrants $ 1 12/29/2016 12/29/2019 Common Stock 200,000 200,000 I See Footnote ( 2 )
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, NY14623
X
Signatures
/s/ Heng Fai Ambrose Chan 09/12/2017
Signature of Reporting Person Date
Explanation of Responses:
( 1 )The Reporting Person is a director of BMI Capital Partners International Ltd. ("BMI Capital"), which owns 300,000 shares of the Issuer's common stock purchased on 12/29/16. The Reporting Person is also the CEO and majority shareholder of Heng Fai Holdings Limited ("HF Holdings"), which owns the 800,000 shares of Issuer's common stock purchased on 9/8/17. Reporting Person has dispositive control over all of these shares.
( 2 )BMI capital owns the previously issued warrants to purchase 200,000 shares of the Issuer's common stock. HF Holdings owns the warrants to purchase 160,000 shares of Issuer's common stock. Reporting Person has dispositive control over all of these warrants.
( 3 )The price of the warrants is included in the price of the shares reported in Table I.

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* If the form is filed by more than one reporting person, see Instruction 4(b)(v).
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