0001104659-21-001916.txt : 20210107 0001104659-21-001916.hdr.sgml : 20210107 20210107115736 ACCESSION NUMBER: 0001104659-21-001916 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210104 FILED AS OF DATE: 20210107 DATE AS OF CHANGE: 20210107 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SAMUELI HENRY CENTRAL INDEX KEY: 0001201633 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38449 FILM NUMBER: 21513499 MAIL ADDRESS: STREET 1: 5300 CALIFORNIA AVENUE CITY: IRVINE STATE: CA ZIP: 92617-3038 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Broadcom Inc. CENTRAL INDEX KEY: 0001730168 STANDARD INDUSTRIAL CLASSIFICATION: SEMICONDUCTORS & RELATED DEVICES [3674] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1101 BUSINESS ADDRESS: STREET 1: 1320 RIDDER PARK DRIVE CITY: SAN JOSE STATE: CA ZIP: 95131 BUSINESS PHONE: 408-433-8000 MAIL ADDRESS: STREET 1: 1320 RIDDER PARK DRIVE CITY: SAN JOSE STATE: CA ZIP: 95131 FORMER COMPANY: FORMER CONFORMED NAME: Broadcom Ltd DATE OF NAME CHANGE: 20180201 4 1 tm211951-1_4.xml OWNERSHIP DOCUMENT X0306 4 2021-01-04 0 0001730168 Broadcom Inc. AVGO 0001201633 SAMUELI HENRY C/O BROADCOM INC. 1320 RIDDER PARK DRIVE SAN JOSE CA 95131 1 0 0 0 Common Stock, $0.001 par value 262582 D Common Stock, par value $0.001k 2021-01-04 5 G 0 E 183600 0 D 4444484 I See Footnote Common Stock. $0.001 par value 1227203 I See Footnote Common Stock, $0.001 par value 2893512 I See Footnote Common Stock, $0.001 par value 459690 I See Footnote Common Stock, $0.001 par value 0 I See Footnote Includes 2,183 restricted stock units. Directly held by D95GT LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. Directly held by E95GT LLC. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. Reflects change in form of beneficial ownership for no consideration in transaction exempt from Section 16 pursuant to Rule 16a-13 under the Securities Exchange Act of 1934. 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. 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. 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/ Henry S. Samueli by Anne G. Plimpton, Attorney in Fact 2021-01-06