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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | 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 control number. | SEC 2270 (9-02) | ||
| 1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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| (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | |||||||||
| Exchangeable Units (1) | Â | 04/10/2017 | Â | W | 2,879 | Â | Â (1) | Â (1) | Ordinary Shares, no par value | $ 0 | 2,879 | See Footnote (2) | ||
| Exchangeable Units (1) | Â | 09/19/2017 | Â | G(3) | Â | 2,879 | Â (1) | Â (1) | Ordinary Shares, no par value | $ 0 | 0 | See Footnote (3) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 53,649 | Â | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 40,058 | See Footnote (4) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 40,058 | See Footnote (5) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 5,752,978 | See Footnote (6) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 399,918 | See Footnote (7) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 459,690 | See Footnote (8) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 2,766,772 | See Footnote (9) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 1,860 | See Footnote (10) | ||
| Exchangeable Units (1) | Â | Â | Â | Â | Â | Â | Â (1) | Â (1) | Ordinary Shares, no par value | Â | 58,800 | See Footnote (11) | ||
| Reporting Owner Name / Address | Relationships | |||
| Director | 10% Owner | Officer | Other | |
| SAMUELI HENRY C/O AVAGO TECHNOLOGIES US INC. 1320 RIDDER PARK DRIVE SAN JOSE, CA 95131 |
 X |  |  Chief Technical Officer |  |
| /s/ Noelle Matteson, Attorney-in-Fact for Henry Samueli | 12/08/2017 | |
| **Signature of Reporting Person | Date |
| * | If the form is filed by more than one reporting person, see Instruction 4(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). |
| (1) | Each Broadcom Cayman LP exchangeable unit ("the Exchangeable Unit") is convertible, at the holder's election, at any time after February 1, 2017, into ordinary shares of the Issuer or a cash amount equal to a prescribed cash amount determined by reference to the weighted average trading price of the Issuer's ordinary shares on NASDAQ for the trading day ending on the last business day prior to the date on which an exchange notice is delivered, at the sole discretion of the Issuer, as the general partner of Broadcom Cayman LP. This conversion right has no expiration date. |
| (2) | Directly held by the Eisenberg 2005 Revocable Trust for which the Reporting Person's spouse is trustee and acquired dispositive power over these Exchangeable Units upon death of the initial trustee (the Reporting Person's mother-in-law). |
| (3) | Charitable gifts by the Eisenberg 2005 Revocable Trust. |
| (4) | Indirectly held by Henry Samueli 2016 GRAT through ownership of membership interests in HS REU, LLC, the direct holder of the Exchangeable Units. |
| (5) | Indirectly held by Susan Faye Samueli 2016 GRAT, a trust for the benefit of the Reporting Person's spouse, through ownership of membership interests in SFS REU, LLC, the direct holder of the Exchangeable Units. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. |
| (6) | Directly held by HS Portfolio L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. |
| (7) | Directly held by HS Management, L.P. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. |
| (8) | 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. |
| (9) | 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. |
| (10) | 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. |
| (11) | Indirectly held by Samueli 1995 Exempt Gifting Trust. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. |