- Initial Statement of Beneficial Ownership (3)
November 07 2011 - 5:26PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Expires:
November 30, 2011
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, 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
*
LaChance Michael J.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
11/4/2011
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3. Issuer Name
and
Ticker or Trading Symbol
MAXLINEAR INC [MXL]
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(Last)
(First)
(Middle)
2051 PALOMAR AIRPORT ROAD, SUITE 100
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
Vice President, Operations /
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(Street)
CARLSBAD, CA 92011
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
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X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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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. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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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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Restricted Stock Units
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(1)
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5/20/2015
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Class A Common Stock (par value $0.0001)
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30000
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(2)
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D
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Stock Option (Right to Buy)
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(3)
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6/30/2018
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Class A Common Stock (par value $0.0001)
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60000
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$8.66
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D
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Explanation of Responses:
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(
1)
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Subject to the Reporting Person's continuining to be a service provider (as defined in the 2010 Equity Incentive Plan) through each such date, twenty five percent (25%) of the restriced stock units ("RSUs") subject to the award shall vest on May 20, 2012, and one-sixteenth (1/16th) of the RSUs subject to the award shall vest on each August 20, November 20, February 20, and May 20 thereafter, such that the award shall be fully vested on May 20, 2015.
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(
2)
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Each RSU represents a contingent right to receive one share of MaxLinear, Inc. Class A Common Stock.
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(
3)
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Subject to the Reporting Person's continuining to be a service provider (as defined in the 2010 Equity Incentive Plan) through each such date, twenty five percent (25%) of the shares subject to the option shall vest and become exercisable on May 2, 2012, and one forty-eighth (1/48th) of the shares subject to the option shall vest and become exercisable each month thereafter, such that the option shall be fully vested and exercisable on the four (4) year anniversary of May 2, 2011.
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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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LaChance Michael J.
2051 PALOMAR AIRPORT ROAD
SUITE 100
CARLSBAD, CA 92011
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Vice President, Operations
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Signatures
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/s/ Patrick E. McCready, as Attorney-in-Fact
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11/7/2011
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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 5(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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