Form 4 Broadcom Inc. For: Mar 15 Filed by: SAMUELI HENRY

March 19, 2019 7:12 PM
FORM 4 UNITED 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
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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 JOSE CA 95131

(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)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
03/15/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form 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)
Code V Amount (A) or (D) Price
Common Stock 03/15/2019 M 2,897 (1) A $ 0 (2) 257,735 (3) D
Common Stock, $0.001 par value 2,815,759 I See Footnote (4)
Common Stock, $0.001 par value 5,752,978 I See Footnote (5)
Common Stock, $0.001 par value 399,918 I See Footnote (6)
Common Stock, $0.001 par value 459,690 I See Footnote (7)
Common Stock, $0.001 par value 1,860 I See Footnote (8)
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)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Performance Based Restricted Stock Units $ 0 03/15/2019 M 2,897 (1) (1) 03/15/2020 Common Stock 2,897.00 $ 0 2,897 D
Explanation of Responses:
1. Shares vested pursuant to a share price performance restricted stock unit award (the "Performance RSU") granted pursuant to the Broadcom Corporation 2012 Stock Incentive Plan on March 15, 2016. The Performance RSU is subject to vest over four years, with 25% vesting on each anniversary of the date of grant, such that the Performance RSU fully vested on March 15, 2020, subject to the Reporting Person's continued service through such date; and provided, however, that no portion of the Performance RSU may vest unless the average of the closing prices of the Issuer's shares (as reported on the stock exchange on which the shares are listed), over a twenty consecutive trading day period is equal to or greater than 120% of the fair market value of the Issuer's shares on the date of grant (the "Price Contingency"). On January 5, 2017, the Price Contingency was met, and on March 15, 2019, the third 25% of the Performance RSU vested.
2. Each Performance RSU represents the right to receive, at settlement, one share of common stock of the Issuer. This transaction represents the settlement of the Performance RSU in the Issuer's shares of common stock on the scheduled vest date.
3. Includes 26,255 RSUs.
4. 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.
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 Portfolio II 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 Ventures LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
/s/ Noelle Matteson, Attorney-in-Fact for Henry S. Samueli 03/19/2019
** Signature of Reporting Person Date
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* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
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