UNITED
STATES
SECURITIES
AND EXCHANGE COMMISSION
Washington,
D.C. 20549
FORM
8-K
CURRENT
REPORT
Pursuant
to Section 13 or 15(d) of the Securities Exchange Act of 1934
Date of
Report (Date of earliest event reported): November 29, 2010
DOCUMENT
SECURITY SYSTEMS, INC.
(Exact
name of registrant as specified in its charter)
New
York
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1-32146
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16-1229730
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||
(State
or other jurisdiction of incorporation)
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(Commission
File Number)
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(IRS
Employer Identification No.)
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First
Federal Plaza, Suite 1525
28
East Main Street
Rochester,
NY
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14614
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(Address
of principal executive offices)
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(Zip
Code)
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Registrant’s
telephone number, including area code: (585) 325-3610
Not
Applicable
(Former
name or former address, if changed since last report.)
Check
the appropriate box below if the Form 8-K filing is intended to simultaneously
satisfy the filing obligation of the registrant under any of the following
provisions (see General Instruction A.2. below):
¨
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Written
communications pursuant to Rule 425 under the Securities Act (17 CFR
230.425)
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¨
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Soliciting
material pursuant to Rule 14a-12 under the Exchange Act (17 CFR
240.14a-12)
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¨
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Pre-commencement
communications pursuant to Rule 14d-2(b) under the Exchange Act (17 CFR
240.14d-2(b))
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¨
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Pre-commencement
communications pursuant to Rule 13e-4(c) under the Exchange Act (17 CFR
240.13e-4(c))
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Item
3.02 Unregistered Sales of Equity Securities.
On November
29, 2010, the holder of a $350,000 Convertible Note dated November 24, 2009,
exercised the conversion feature of the note for 218,750 shares of Document
Security Systems Common Stock, par value $0.02 which retired the debt in
full.
Item
9.01 Financial Statements and Exhibits
(d) Exhibits
Exhibit No.
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Description
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10.1
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$350,000
Convertible Promissory Note dated November 24, 2009.( (incorporated herein
by reference from registrant’s Current Report on Form 8-K filed with the
SEC on December 15, 2009).
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SIGNATURE
Pursuant
to the requirements of the Securities Exchange Act of 1934, the Registrant has
duly caused this report to be signed on its behalf by the undersigned hereunto
duly authorized.
DOCUMENT
SECURITY SYSTEMS, INC.
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Dated:
December 1,
2010
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By:
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/s/
Patrick A. White
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Patrick
A. White
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Chief
Executive Officer
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EXHIBIT
INDEX
Exhibit
Number
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Description
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4.1
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Form
of Warrant to Purchase Common Stock of Document Security Systems, Inc.
dated May 29, 2009.*
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10.1
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Form
of Subscription Agreement dated as of May 29, 2009 between Document
Security Systems, Inc. and the Subscribers.*
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10.2
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Form
of Registration Rights Agreement dated as of May 29, 2009 executed and
delivered by Document Security Systems, Inc. and the holders listed
therein.*
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* Such
exhibit was filed as an exhibit to the Current Report on Form 8-K that was filed
by Document Security Systems, Inc. with the SEC on June 3, 2009, and is
incorporated herein by reference.