SEC Info℠  
    Home      Search      My Interests      Help      Sign In      Please Sign In

Samueli Henry – ‘4’ for 9/18/20 re: Broadcom Inc.

On:  Monday, 9/21/20, at 4:33pm ET   ·   For:  9/18/20   ·   Accession #:  1104659-20-107002   ·   File #:  1-38449

Previous ‘4’:  ‘4’ on 6/15/20 for 6/9/20   ·   Next:  ‘4’ on 1/7/21 for 1/4/21   ·   Latest:  ‘4’ on 4/24/24 for 4/22/24

Find Words in Filings emoji
 		  in    Show  and   ↓Hints

  As Of               Filer                 Filing    For·On·As Docs:Size             Issuer                      Filing Agent

 9/21/20  Samueli Henry                     4                      1:10K  Broadcom Inc.                     Toppan Merrill/FA

Statement of Changes in Beneficial Ownership of Securities by an Insider   —   Form 4   —   SEA’34
Filing Table of Contents

Document/Exhibit                   Description                      Pages   Size 

 1: 4           Statement of Changes in Beneficial Ownership of     HTML      3K 
                Securities by an Insider --                                      
                tm2031404d1_form4.xml/3.6


        

This ‘4’ Document is an XML Data File that may be rendered in various formats:

  Form 4    –   Plain Text   –  SEC Website  –  EDGAR System  –    XML Data    –  <?xml?> File
 
 
SEC Website rendering:  Statement of Changes in Beneficial Ownership of Securities by an Insider
 
SEC Form 4
FORM 4UNITED 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
or Section 30(h) of the Investment Company Act of 1940
OMB APPROVAL
OMB Number:3235-0287
Estimated average burden
hours per response:0.5
  
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
SAMUELI HENRY
(Last)(First)(Middle)
C/O BROADCOM INC.
1320 RIDDER PARK DRIVE
(Street)
SAN JOSECA95131
(City)(State)(Zip)
2. Issuer Name and Ticker or Trading Symbol
Broadcom Inc. [ AVGO ] 		5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
XDirector 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
09/18/2020
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
XForm filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year)2A. Deemed Execution Date, if any (Month/Day/Year)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)
CodeVAmount(A) or (D)Price
Common Stock, $0.001 par value 262,582 (1)D
Common Stock, par value $0.001k09/18/2020GV38,850A$04,628,084 (4)ISee Footnote (2)
Common Stock. $0.001 par value09/18/2020GV131,062A$01,227,203 (4)ISee Footnote (3)
Common Stock, $0.001 par value 0 (4)ISee Footnote (5)
Common Stock, $0.001 par value 0 (4)ISee Footnote (6)
Common Stock, $0.001 par value09/18/2020P 101,740A$361.452,832,299ISee Footnote (7)
Common Stock, $0.001 par value 459,690ISee Footnote (8)
Common Stock, $0.001 par value 61,213 (4)ISee Footnote (9)
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 (Month/Day/Year)3A. Deemed Execution Date, if any (Month/Day/Year)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 (Month/Day/Year)7. Title and Amount of Securities Underlying Derivative Security (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: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
CodeV(A)(D)Date ExercisableExpiration DateTitleAmount or Number of Shares
Explanation of Responses:
1. Includes 2,641 restricted stock units.
2. Directly held by D95GT LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
3. Directly held by E95GT LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
4. Reflects change in form of beneficial ownership for no consideration in transaction exempt from Section 16 pursuant to Rule 16a-13 under the Securities Exchange Act of 1934.
5. 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.
6. 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.
7. Directly held by H&S Investments I L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
8. 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.
9. 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.
/s/ Henry S. Samueli by Anne G. Plimpton, Attorney in Fact09/21/2020
** Signature of Reporting PersonDate
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
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 Number.

↑Top
Filing Submission 0001104659-20-107002   –   Alternative Formats (Word / Rich Text, HTML, Plain Text, et al.)
Copyright © 2024 Fran Finnegan & Company LLC – All Rights Reserved.
About — Privacy — Redactions — Help — Mon., Apr. 29, 9:06:54.2pm ET