SEC Form 4 · accession 0001144204-17-035257

Broadcom Ltd · AVGO

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owner

Henry Samueli

Officer — Chief Technical Officer · Director

Period of report

Jun 28, 2017

Accepted (ET)

Jun 30, 2017 · 4:40 pm EDT

Rule 10b5-1 plan

unknown — predates the checkbox

Issuer CIK

0001649338

Table I — non-derivative securities

No Table I lines on this filing.

Table II — derivative securities

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Exchangeable Units^F1,F2	—	Jun 28, 2017	P	62,010	A	—	—	Ordinary Shares, no par value	62,010	40,058	I
Exchangeable Units^F1,F3	—	Jun 28, 2017	P	62,010	A	—	—	Ordinary Shares, no par value	62,010	40,058	I
Exchangeable Units^F1	—	holding	—	—	—	—	—	Ordinary Shares, no par value	53,649	53,649	D
Exchangeable Units^F1,F4	—	holding	—	—	—	—	—	Ordinary Shares, no par value	5,752,978	5,752,978	I
Exchangeable Units^F1,F5	—	holding	—	—	—	—	—	Ordinary Shares, no par value	399,918	399,918	I
Exchangeable Units^F1,F6	—	holding	—	—	—	—	—	Ordinary Shares, no par value	459,690	459,690	I
Exchangeable Units^F1,F7	—	holding	—	—	—	—	—	Ordinary Shares, no par value	2,766,772	2,766,772	I
Exchangeable Units^F1,F8	—	holding	—	—	—	—	—	Ordinary Shares, no par value	1,860	1,860	I

Explanation of responses

F1Each Broadcom Cayman LP exchangeable unit is convertible, at the Reporting Person's election, at any time after February 1, 2017, into ordinary shares of the Issuer or a cash amount equal to a prescribed cash amount determined by reference to the weighted average trading price of the Issuer's ordinary shares on NASDAQ for the trading day ending on the last business day prior to the date on which an exchange notice is delivered, at the sole discretion of the Issuer, as the general partner of Broadcom Cayman LP. This conversion right has no expiration date.
F2Indirectly held by Henry Samueli 2016 GRAT through ownership of membership interests in HS REU, LLC, the direct holder of the Units. Number of Units adjusted to reflect change in the form of the Reporting Person's indirect ownership of 21,951.54 Units for no consideration, in transfer exempt from Section 16 of the Securities Exchange Act of 1934 pursuant to Rule 16a-13 thereunder.
F3Indirectly held by Susan Faye Samueli 2016 GRAT, a trust for the benefit of the Reporting Person's spouse, through ownership of membership interests in SFS REU, LLC, the direct holder of the Units. Number of Units adjusted to reflect change in the form of the Reporting Person's indirect ownership of 21,951.54 Units for no consideration, in transfer exempt from Section 16 of the Securities Exchange Act of 1934 pursuant to Rule 16a-13 thereunder. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F4Directly held by HS Portfolio L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F5Directly held by HS Management, L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F6Directly 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.
F7Directly held by H&S Investments I L.P. Number of Units adjusted to reflect change in the form of the Reporting Person's indirect ownership of 43,903.08 Units (directly held by HS REU LLC and SFS REU LLC) for no consideration, in transfers exempt from Section 16 of the Securities Exchange Act of 1934 pursuant to Rule 16a-13 thereunder. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F8Directly held by H&S Ventures LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.