Sec Form 4 Filing - SAMUELI HENRY @ Broadcom Inc. - 2018-04-04

Insider filing report for Changes in Beneficial Ownership
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FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
SAMUELI HENRY
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
X __ Officer (give title below) _____ Other (specify below)
Chief Technical Officer
(Last) (First) (Middle)
C/O BROADCOM INC., 1320 RIDDER PARK DRIVE
3. Date of Earliest Transaction (MM/DD/YY)
04/04/2018
(Street)
SAN JOSE, CA95131
4. If Amendment, Date Original Filed (MM/DD/YY)
6. Individual or Joint/Group Filing (Check Applicable Line)
__ X __ Form filed by One Reporting Person
_____ Form filed by More than One Reporting Person
(City) (State) (Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 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, $0.001 par value 04/04/2018 J( 1 ) 53,649 A $ 0 254,338 ( 2 ) D
Common Stock, $0.001 par value 04/04/2018 J( 1 ) 40,058 A $ 0 40,058 I See Footnote ( 3 )
Common Stock, $0.001 par value 04/04/2018 J( 1 ) 40,058 A $ 0 40,058 I See Footnote ( 4 )
Common Stock, $0.001 par value 04/04/2018 J( 1 ) 5,752,978 A $ 0 5,752,978 I See Footnote ( 5 )
Common Stock, $0.001 par value 04/04/2018 J( 1 ) 399,918 A $ 0 399,918 I See Footnote ( 6 )
Common Stock, $0.001 par value 04/04/2018 J( 1 ) 459,690 A $ 0 459,690 I See Footnote ( 7 )
Common Stock, $0.001 par value 04/04/2018 J( 1 ) 2,766,772 A $ 0 2,766,772 I See Footnote ( 8 )
Common Stock, $0.001 par value 04/04/2018 J( 1 ) 1,860 A $ 0 1,860 I See Footnote ( 9 )
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 (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 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
(MM/DD/YY)
7. Title and Amount of Underlying Securities
(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 of Derivative Security: 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
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 53,649 ( 1 ) ( 1 ) Common Stock 53,649 $ 0 0 D
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 40,058 ( 1 ) ( 1 ) Common Stock 40,058 $ 0 0 I See Footnote ( 3 )
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 40,058 ( 1 ) ( 1 ) Common Stock 40,058 $ 0 0 I See Footnote ( 4 )
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 5,752,978 ( 1 ) ( 1 ) Common Stock 5,752,978 $ 0 0 I See Footnote ( 5 )
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 399,918 ( 1 ) ( 1 ) Common Stock 399,918 $ 0 0 I See Footnote ( 6 )
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 459,690 ( 1 ) ( 1 ) Common Stock 459,690 $ 0 0 I See Footnote ( 7 )
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 2,766,772 ( 1 ) ( 1 ) Common Stock 2,766,772 $ 0 0 I See Footnote ( 8 )
Exchangeable Units ( 1 ) ( 1 ) 04/04/2018 J( 1 ) 1,860 ( 1 ) ( 1 ) Common Stock 1,860 $ 0 0 I See Footnote ( 9 )
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
SAMUELI HENRY
C/O BROADCOM INC.
1320 RIDDER PARK DRIVE
SAN JOSE, CA95131
X Chief Technical Officer
Signatures
/s/ Noelle Matteson, Attorney-in-Fact for Henry S. Samueli 04/06/2018
Signature of Reporting Person Date
Explanation of Responses:
( 1 )In connection with the Redomiciliation (as defined in "Remarks" below), each exchangeable partnership unit of Broadcom Cayman L.P. (the "Exchangeable Unit"), an exempted limited partnership registered in the Cayman Islands of which Broadcom Limited was the general partner ("Broadcom Cayman L.P.") was converted on a one-for-one basis into a newly issued shares of common stock of Broadcom Inc.
( 2 )Includes 73,496 restricted stock units.
( 3 )Indirectly 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.
( 4 )Indirectly 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 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 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.
( 9 )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.

Remarks:
On April 4, 2018, Broadcom Inc., a Delaware corporation, became the successor of Broadcom Limited, a company organized under the laws of the Republic of Singapore ("Broadcom Limited"), pursuant to a scheme of arrangement under Singapore law under which all issued ordinary shares in the capital of Broadcom Limited were exchanged on a one-for-one basis for shares of common stock of Broadcom Inc. (the "Redomiciliation"). The Redomiciliation had the effect of changing Broadcom Limited's domicile, but did not alter the proportionate interests of shareholders.

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