Henry Samueli Form 4 Broadcom / HENRY SAMUELI ownership change

SEC Form 4

FORM 4

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

1. Name and Address of Reporting Person^*

SAMUELI HENRY

(Last) (First) (Middle)

C/O BROADCOM INC.

1320 RIDDER PARK DRIVE

(Street)

SAN JOSE CA 95131

(City) (State) (Zip)

2. Issuer Name and Ticker or Trading Symbol
Broadcom Inc. [ AVGO ]

5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	10% Owner
X	Officer (give title below)	Other (specify below)
Chief Technical Officer

3. Date of Earliest Transaction (Month/Day/Year)
04/13/2018

4. 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 Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3)	2. Transaction Date (Month/Day/Year)	2A. Deemed Execution Date, if any (Month/Day/Year)	3. Transaction Code (Instr. 8)		4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5)			5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)	6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)
			Code	V	Amount	(A) or (D)	Price
Common Stock, $0.001 par value	04/13/2018		J(9)		24,494	D	$248.45	15,564.5	I	See Footnote(1)
Common Stock, $0.001 par value	04/13/2018		J(9)		24,494	D	$248.45	15,564.5	I	See Footnote(2)
Common Stock, $0.001 par value								2,815,760(10)	I	See Footnote(3)
Common Stock, $0.001 par value								254,338(4)	D
Common Stock, $0.001 par value								5,752,978	I	See Footnote(5)
Common Stock, $0.001 par value								399,918	I	See Footnote(6)
Common Stock, $0.001 par value								459,690	I	See Footnote(7)
Common Stock, $0.001 par value								1,860	I	See Footnote(8)

Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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 Securities Underlying Derivative Security (Instr. 3 and 4)		8. Price of Derivative Security (Instr. 5)	9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)	10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
				Code	V	(A)	(D)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares

Explanation of Responses:

1. Indirectly held by Henry Samueli 2016 GRAT, a trust for which the Reporting Person is trustee, through ownership of membership interests in HS REU, LLC, the direct holder of the common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.

2. Indirectly held by Susan Faye Samueli 2016 GRAT, a trust for which the Reporting Person's spouse is trustee, through ownership of membership interests in SFS REU, LLC, the direct holder of the common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest.

3. Directly held by H&S Investments I L.P. and through its ownership of membership interests in HS REU, LLC and SFS REU, LLC, direct holders of certain shares of common stock. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.

4. Includes 73,496 restricted stock units.

5. 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.

6. 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.

7. 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.

8. 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.

9. Change in form of beneficial ownership as a result of property substitution.

10. Includes 48,988 shares transferred in connection with a change in form of beneficial ownership for no consideration which was exempt from Section 16 pursuant to Rule 16a-13 under the Securities Exchange Act of 1934, as amended.

	/s/ Anne G. Plimpton Attorney-in-Fact for Henry S. Samueli	04/14/2018
	** 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 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).
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