Statement of Changes in Beneficial Ownership (4)
08 Décembre 2018 - 12:52AM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
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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Brazeal Mark David
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2. Issuer Name
and
Ticker or Trading Symbol
Broadcom Inc.
[
AVGO
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chief Legal Officer
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(Last)
(First)
(Middle)
C/O BROADCOM INC., 1320 RIDDER PARK DRIVE
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3. Date of Earliest Transaction
(MM/DD/YYYY)
12/4/2018
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(Street)
SAN JOSE, CA 95131
(City)
(State)
(Zip)
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4. 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 Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock, $0.001 par value
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12/4/2018
(1)
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A
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30000
(2)
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A
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$0
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52633
(3)
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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. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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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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Explanation of Responses:
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(1)
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Award approved on December 4, 2018 with an effective grant date of January 15, 2019.
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(2)
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Award of Restricted Stock Units ("RSUs") granted pursuant to the Avago Technologies Limited 2009 Equity Incentive Award Plan. Upon vesting thereof, the Reporting Person is entitled to one (1) share of common stock for each one (1) RSU. This award consists of four grants, each for 7,500 RSUs, and is intended to approximate four consecutive annual equity grants with successive four-year vesting periods. 25% of the shares underlying each grant vests on each annual anniversary of the vesting commencement date applicable to such grant. The four grants have successive vesting commencement dates of March 15, 2019, March 15, 2020, March 15, 2021 and March 15, 2022, such that the fourth grant under the award will not vest in full on until March 15, 2026, subject to continued service with the Issuer.
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(3)
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Includes 48,875 RSUs.
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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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Brazeal Mark David
C/O BROADCOM INC.
1320 RIDDER PARK DRIVE
SAN JOSE, CA 95131
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Chief Legal Officer
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Signatures
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/s/ Noelle Matteson, Attorney-in-Fact for Mark Brazeal
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12/7/2018
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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 4(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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