0001730168-21-000034.txt : 20210304 0001730168-21-000034.hdr.sgml : 20210304 20210304172200 ACCESSION NUMBER: 0001730168-21-000034 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210302 FILED AS OF DATE: 20210304 DATE AS OF CHANGE: 20210304 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: 21715355 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 wf-form4_161489649018818.xml FORM 4 X0306 4 2021-03-02 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 2021-03-02 4 A 0 500 0 A 263082 D Common Stock, $0.001 par value 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 On March 2, 2021, the Compensation Committee of the Issuer determined the achievement of certain performance criteria, based on the Issuer's compound annual total stockholder return relative to the S&P 500 Index, and the number of restricted stock units ("RSUs") that will vest with respect to the third of four performance periods pursuant to the terms of a performance stock unit award granted on March 15, 2018 under the Broadcom Corporation 2012 Stock Incentive Plan. The RSUs are subject to time-based vesting conditions and will vest in full on March 15, 2021, subject to the Reporting Person's continued service through such date. Upon vesting thereof, the Reporting Person is entitled to one (1) share of common stock for each one (1) RSU. Includes 2,225 RSUs. 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. 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. /s/ Noelle Matteson, Attorney-in-Fact for Henry S. Samueli 2021-03-04