Statement of Changes in Beneficial Ownership (4)
April 17 2018 - 2:22PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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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1. Name and Address of Reporting Person
*
SAMUELI HENRY
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2. Issuer Name
and
Ticker or Trading Symbol
Broadcom Inc.
[
AVGO
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chief Technical Officer
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(Last)
(First)
(Middle)
C/O BROADCOM INC., 1320 RIDDER PARK DRIVE
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3. Date of Earliest Transaction
(MM/DD/YYYY)
4/13/2018
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(Street)
SAN JOSE, CA 95131
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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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. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. 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, $0.001 par value
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4/13/2018
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J
(9)
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24494
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D
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$248.45
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15564.5
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I
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See Footnote
(1)
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Common Stock, $0.001 par value
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4/13/2018
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J
(9)
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24494
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D
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$248.45
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15564.5
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I
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See Footnote
(2)
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Common Stock, $0.001 par value
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2815760
(10)
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I
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See Footnote
(3)
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Common Stock, $0.001 par value
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254338
(4)
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D
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Common Stock, $0.001 par value
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5752978
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I
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See Footnote
(5)
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Common Stock, $0.001 par value
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399918
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I
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See Footnote
(6)
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Common Stock, $0.001 par value
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459690
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I
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See Footnote
(7)
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Common Stock, $0.001 par value
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1860
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I
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See Footnote
(8)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. 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
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7. Title and Amount of Securities Underlying Derivative Security
(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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Explanation of Responses:
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(1)
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Indirectly held by Henry Samueli 2016 GRAT, a trust for which the Reporting Person is trustee, through ownership of membership interests in HS REU, LLC, the direct holder of the common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
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(2)
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Indirectly held by Susan Faye Samueli 2016 GRAT, a trust for which the Reporting Person's spouse is trustee, through ownership of membership interests in SFS REU, LLC, the direct holder of the common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest.
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(3)
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Directly held by H&S Investments I L.P. and through its ownership of membership interests in HS REU, LLC and SFS REU, LLC, direct holders of certain shares of common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
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(4)
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Includes 73,496 restricted stock units.
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(5)
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Directly held by HS Portfolio L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
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(6)
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Directly held by HS Management, L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
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(7)
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Directly held by H&S Portfolio II L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
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(8)
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Directly held by H&S Ventures LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
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(9)
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Change in form of beneficial ownership as a result of property substitution.
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(10)
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Includes 48,988 shares transferred in connection with a change in form of beneficial ownership for no consideration which was exempt from Section 16 pursuant to Rule 16a-13 under the Securities Exchange Act of 1934, as amended.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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SAMUELI HENRY
C/O BROADCOM INC.
1320 RIDDER PARK DRIVE
SAN JOSE, CA 95131
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X
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Chief Technical Officer
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Signatures
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/s/ Anne G. Plimpton Attorney-in-Fact for Henry S. Samueli
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4/14/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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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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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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