Henry Samueli Form 5 Broadcom / HENRY SAMUELI ownership change

SEC Form 5

FORM 5

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

ANNUAL 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).

Form 3 Holdings Reported.

Form 4 Transactions Reported.

1. Name and Address of Reporting Person^*

SAMUELI HENRY

(Last)

(First)

(Middle)

C/O AVAGO TECHNOLOGIES US INC.

1320 RIDDER PARK DRIVE

(Street)

SAN JOSE

95131

(City)

(State)

(Zip)

2. Issuer Name and Ticker or Trading Symbol
Broadcom Ltd [ 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. Statement for Issuer's Fiscal Year Ended (Month/Day/Year)
10/29/2017

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 at end of Issuer's Fiscal Year (Instr. 3 and 4)	6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)
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)	Amount	(A) or (D)	Price		6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)

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)
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)	(A)	(D)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	8. Price of Derivative Security (Instr. 5)		10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
Exchangeable Units⁽¹⁾	⁽¹⁾	04/10/2017		W	2,879		⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	2,879	$0	2,879	I	See Footnote⁽²⁾
Exchangeable Units⁽¹⁾	⁽¹⁾	09/19/2017		G⁽³⁾		2,879	⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	2,879	$0	0	I	See Footnote⁽³⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	53,649		53,649	D
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	40,058		40,058	I	See Footnote⁽⁴⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	40,058		40,058	I	See Footnote⁽⁵⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	5,752,978		5,752,978	I	See Footnote⁽⁶⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	399,918		399,918	I	See Footnote⁽⁷⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	459,690		459,690	I	See Footnote⁽⁸⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	2,766,772		2,766,772	I	See Footnote⁽⁹⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	1,860		1,860	I	See Footnote⁽¹⁰⁾
Exchangeable Units⁽¹⁾	⁽¹⁾						⁽¹⁾	⁽¹⁾	Ordinary Shares, no par value	58,800		58,800	I	See Footnote⁽¹¹⁾

Explanation of Responses:

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.

Remarks:

	/s/ Noelle Matteson, Attorney-in-Fact for Henry Samueli	12/08/2017
	** 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).
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.

Henry Samueli Form 5Broadcom / HENRY SAMUELI ownership change