Initial Statement of Beneficial Ownership (3)
October 19 2017 - 4:30PM
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
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
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CARLSON DOUGLAS J
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2. Date of Event Requiring Statement (MM/DD/YYYY)
10/9/2017
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3. Issuer Name
and
Ticker or Trading Symbol
MACOM Technology Solutions Holdings, Inc. [MTSI]
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(Last)
(First)
(Middle)
C/O MACOM TECHNOLOGY SOLUTIONS HOLDINGS, 100 CHELMSFORD STREET
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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)
SVP & GM, RF & Microwave /
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(Street)
LOWELL, MA 01851
(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)
_
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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Common Stock
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14672
(1)
(2)
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D
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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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Stock Option (Right to Buy)
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(3)
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8/14/2020
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Common Stock
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600
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$2.00
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D
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Stock Option (Right to Buy)
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(4)
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11/13/2022
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Common Stock
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10000
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$32.10
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D
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Stock Option (Right to Buy)
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(5)
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11/9/2023
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Common Stock
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20000
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$40.25
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D
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Explanation of Responses:
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(1)
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Includes (i) 4,000 restricted stock units ("RSUs") granted on March 14, 2017, which vest as follows: 1,000 RSUs vest on February 15, 2018, 1,000 RSUs vest on February 15, 2019, 1,000 RSUs vest on February 15, 2020 and 1,000 RSUs vest on February 15, 2021, provided that the Reporting Person remains in continuous service with the Issuer through each vesting date; (ii) 2,383 RSUs granted on March 17, 2016, which vest as follows: 794 RSUs vest on February 15, 2018, 794 RSUs vest on February 15, 2019 and 795 RSUs vest on February 15, 2020, provided that the Reporting Person remains in continuous service with the Issuer through each vesting date; [continued below]
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(2)
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(iii) 1,806 RSUs granted on March 23, 2015, which vest as follows: 903 RSUs vest on February 15, 2018 and 903 RSUs vest on vest on February 15, 2019, provided that the Reporting Person remains in continuous service with the Issuer through each vesting date; and (iv) 875 RSUs granted on January 29, 2014, which vest on February 15, 2018, provided that the Reporting Person remains in continuous service with the Issuer through such vesting date. All RSUs were granted to the Reporting Person under the Issuer's 2012 Omnibus Incentive Plan and each RSU represents the contingent right to receive one share of Common Stock.
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(3)
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The Stock Option vested in full on August 1, 2014.
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(4)
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100% of the Stock Option shall become vested and exercisable in the event that the 30 trading day trailing average closing price per share of the Common Stock meets or exceeds $64.22 per share.
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(5)
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100% of the Stock Option shall become vested and exercisable in the event that the 30 trading day trailing average closing price per share of the Common Stock meets or exceeds $66.96 per share.
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Remarks:
Exhibit List: Exhibit 24 - Power of Attorney
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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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CARLSON DOUGLAS J
C/O MACOM TECHNOLOGY SOLUTIONS HOLDINGS
100 CHELMSFORD STREET
LOWELL, MA 01851
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SVP & GM, RF & Microwave
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Signatures
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/s/ Clay Simpson, Attorney-in-Fact
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10/19/2017
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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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