SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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*
Struble Wayne Mack

(Last) (First) (Middle)
C/O MACOM TECHNOLOGY SOLUTIONS HOLDINGS
100 CHELMSFORD STREET

(Street)
LOWELL MA 01851

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
08/02/2023
3. Issuer Name and Ticker or Trading Symbol
MACOM Technology Solutions Holdings, Inc. [ MTSI ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
SVP, Advanced Semiconductor
5. 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 Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock 8,829(1) D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Explanation of Responses:
1. Includes (i) 1,674 restricted stock units ("RSUs") granted on October 27, 2020, which vest as follows: 836 shares on October 27, 2023 and 838 shares on October 27, 2024; (ii) 2,046 RSUs granted on October 27, 2021, which vest as follows: 1,022 shares on October 27, 2023 and 1,024 shares on October 27, 2024; and (iii) 2,788 RSUs granted on October 27, 2022, which vest as follows: 929 shares on October 27, 2023, 929 shares on October 27, 2024, and 930 shares on October 27, 2025, provided with respect to each vesting event described herein that the Reporting Person remains in continuous service with the Issuer through such vesting date. All RSUs were granted to the Reporting Person under the Issuer's 2012 or 2021 Omnibus Incentive Plan and each RSU represents the contingent right to receive one share of Common Stock.
Remarks:
Exhibit List: Exhibit 24 - Power of Attorney
/s/ Ambra R. Roth, Attorney-in-Fact 08/04/2023
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
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 Number.