SEC FORM 4 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*
TAN HOCK E

(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)
President and CEO
3. Date of Earliest Transaction (Month/Day/Year)
10/31/2022
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 01/04/2022 G(1) V 48,000 D $0 286,677 D
Common Stock, $0.001 par value 03/23/2022 G(1) V 20,000 D $0 266,677 D
Common Stock, $0.001 par value 03/25/2022 G(1) V 16,000 D $0 250,677 D
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
Stock Price Performance Stock Unit $0.0 10/31/2022 A 1,000,000 (2) (3) Common Stock, $0.001 par value 1,000,000 $0 1,000,000 D
Explanation of Responses:
1. Charitable gift.
2. Stock price performance stock unit award (the "PSU") granted pursuant to the Broadcom Inc. 2012 Stock Incentive Plan. Subject to the terms and conditions of the PSU agreement, the PSU vests on October 31, 2027. The number of shares that may be earned is based on achieving pre-set price hurdles (the "Price Contingency"). No portion of the PSU will be earned unless the consecutive 20-trading days closing price average of the Issuer's common stock meets or exceeds the Price Contingency during the period beginning after the third anniversary of the grant date and concluding on the fifth anniversary of the grant date.
3. If the Price Contingency is not met on or prior to the fifth anniversary of the grant date or such earlier date as provided in the PSU agreement, all PSUs will immediately be forfeited.
Remarks:
/s/ Noelle Matteson, Attorney-in-Fact for Hock E. Tan 11/02/2022
** 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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