SEC Form 4 · accession 0001144204-18-020900
Broadcom Inc. · AVGO
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Henry Samueli
Officer — Chief Technical Officer · Director
Period of report
Apr 13, 2018
Accepted (ET)
Apr 17, 2018 · 2:21 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001730168
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common Stock, $0.001 par valueF1 | Apr 13, 2018 | J | 24,494 | $248.45 | D | 15,565 | I | See Footnote |
| Common Stock, $0.001 par valueF2 | Apr 13, 2018 | J | 24,494 | $248.45 | D | 15,565 | I | See Footnote |
| Common Stock, $0.001 par valueF10,F3 | holding | — | — | — | 2,815,760 | I | See Footnote | |
| Common Stock, $0.001 par valueF4 | holding | — | — | — | 254,338 | D | ||
| Common Stock, $0.001 par valueF5 | holding | — | — | — | 5,752,978 | I | See Footnote | |
| Common Stock, $0.001 par valueF6 | holding | — | — | — | 399,918 | I | See Footnote | |
| Common Stock, $0.001 par valueF7 | holding | — | — | — | 459,690 | I | See Footnote | |
| Common Stock, $0.001 par valueF8 | holding | — | — | — | 1,860 | I | See Footnote |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1Indirectly held by Henry Samueli 2016 GRAT, a trust for which the Reporting Person is trustee, through ownership of membership interests in HS REU, LLC, the direct holder of the common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
- F10Includes 48,988 shares transferred in connection with a change in form of beneficial ownership for no consideration which was exempt from Section 16 pursuant to Rule 16a-13 under the Securities Exchange Act of 1934, as amended.
- F2Indirectly held by Susan Faye Samueli 2016 GRAT, a trust for which the Reporting Person's spouse is trustee, through ownership of membership interests in SFS REU, LLC, the direct holder of the common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest.
- F3Directly held by H&S Investments I L.P. and through its ownership of membership interests in HS REU, LLC and SFS REU, LLC, direct holders of certain shares of common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
- F4Includes 73,496 restricted stock units.
- F5Directly held by HS Portfolio L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
- F6Directly held by HS Management, 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 Portfolio II 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 Ventures LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
- F9Change in form of beneficial ownership as a result of property substitution.