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