0001730168-21-000118.txt : 20210621 0001730168-21-000118.hdr.sgml : 20210621 20210621171149 ACCESSION NUMBER: 0001730168-21-000118 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210617 FILED AS OF DATE: 20210621 DATE AS OF CHANGE: 20210621 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: TAN HOCK E CENTRAL INDEX KEY: 0001211588 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38449 FILM NUMBER: 211031797 MAIL ADDRESS: STREET 1: BROADCOM INC. STREET 2: 1320 RIDDER PARK DRIVE CITY: SAN JOSE STATE: CA ZIP: 95131 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: 1031 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_162430986932124.xml FORM 4 X0306 4 2021-06-17 0 0001730168 Broadcom Inc. AVGO 0001211588 TAN HOCK E C/O BROADCOM INC. 1320 RIDDER PARK DRIVE SAN JOSE CA 95131 1 1 0 0 President and CEO Common Stock, $0.001 par value 2021-06-17 4 A 0 363996 0 A 581828 D Common Stock, $0.001 par value 2021-06-17 4 F 0 180151 471.17 D 401677 D On June 17, 2021, the independent members of the Issuer's Board of Directors determined the achievement of certain performance criteria, based on the Issuer's total stockholder return ("TSR") performance as compared to the S&P 500 Index and the Issuer's absolute TSR, over a four year performance period ending on June 14, 2021, and the number of shares of common stock earned and issuable pursuant to the terms of a performance stock unit award granted on June 15, 2017 (the "2017 Award") under the Avago Technologies Limited 2009 Equity Incentive Award Plan. Consists of shares withheld by the Issuer to satisfy the tax withholding obligations of the Reporting Person upon the vesting of the 2017 Award. /s/ Noelle Matteson, Attorney-in-Fact for Hock E. Tan 2021-06-21