SEC Form 5 · accession 0001649338-17-000141

Broadcom Ltd · AVGO

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

A later amendment supersedes this filing — read the amendment. The figures below are kept as originally reported (version chain, not an overwrite).

Reporting owner

Henry Samueli

Officer — Chief Technical Officer · Director

Period of report

Oct 29, 2017

Accepted (ET)

Dec 8, 2017 · 5:19 pm EST

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	—	Apr 10, 2017	W	2,879	A	—	—	Ordinary Shares, no par value	2,879	2,879	I
Exchangeable Units^F1,F3	—	Sep 19, 2017	G	2,879	D	—	—	Ordinary Shares, no par value	2,879	0	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	40,058	40,058	I
Exchangeable Units^F1,F5	—	holding	—	—	—	—	—	Ordinary Shares, no par value	40,058	40,058	I
Exchangeable Units^F1,F6	—	holding	—	—	—	—	—	Ordinary Shares, no par value	5,752,978	5,752,978	I
Exchangeable Units^F1,F7	—	holding	—	—	—	—	—	Ordinary Shares, no par value	399,918	399,918	I
Exchangeable Units^F1,F8	—	holding	—	—	—	—	—	Ordinary Shares, no par value	459,690	459,690	I
Exchangeable Units^F1,F9	—	holding	—	—	—	—	—	Ordinary Shares, no par value	2,766,772	2,766,772	I
Exchangeable Units^F1,F10	—	holding	—	—	—	—	—	Ordinary Shares, no par value	1,860	1,860	I
Exchangeable Units^F1,F11	—	holding	—	—	—	—	—	Ordinary Shares, no par value	58,800	58,800	I

Explanation of responses

F1Each Broadcom Cayman LP exchangeable unit ("the Exchangeable Unit") is convertible, at the holder'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.
F10Directly held by H&S Ventures LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F11Indirectly held by Samueli 1995 Exempt Gifting Trust. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F2Directly held by the Eisenberg 2005 Revocable Trust for which the Reporting Person's spouse is trustee and acquired dispositive power over these Exchangeable Units upon death of the initial trustee (the Reporting Person's mother-in-law).
F3Charitable gifts by the Eisenberg 2005 Revocable Trust.
F4Indirectly held by Henry Samueli 2016 GRAT through ownership of membership interests in HS REU, LLC, the direct holder of the Exchangeable Units.
F5Indirectly 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 Exchangeable Units. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F6Directly held by HS Portfolio L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F7Directly held by HS Management, L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
F8Directly 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.
F9Directly 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.