SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS, |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
02/01/2016
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3. Issuer Name and Ticker or Trading Symbol
Broadcom Ltd
[ AVGO ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Form filed by One Reporting Person |
| X |
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS, |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
|
1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
|
1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
|
1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
|
1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
|
1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
|
1. Name and Address of Reporting Person*
| C/O SILVER LAKE PARTNERS |
| 2775 SAND HILL ROAD, SUITE 100 |
(Street)
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| Explanation of Responses: |
| Remarks: |
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| No securities are beneficially owned. |
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/s/ Karen M. King, Director of Silver Lake (Offshore) AIV GP IV Ltd. |
02/01/2016 |
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/s/ Karen M. King, Director of Silver Lake (Offshore) AIV GP IV Ltd., General Partner of Silver Lake Technology Associates IV Cayman, L.P. |
02/01/2016 |
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/s/ Karen M. King, Director of Silver Lake (Offshore) AIV GP IV Ltd., General Partner of Silver Lake Technology Associates IV Cayman, L.P., General Partner of Silver Lake Partners IV Cayman (AIV II), L.P. |
02/01/2016 |
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/s/ Karen M. King, Director of Silver Lake (Offshore) AIV GP IV Ltd., General Partner of Silver Lake Technology Associates IV Cayman, L.P., General Partner of Silver Lake Technology Investors IV Cayman, L.P. |
02/01/2016 |
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/s/ Karen M. King, General Counsel of SLP Argo I Ltd. |
02/01/2016 |
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/s/ Karen M. King, General Counsel of SLP Argo II Ltd. |
02/01/2016 |
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/s/ Kenneth Y. Hao, by Karen M. King, Attorney-in-fact for Kenneth Y. Hao |
02/01/2016 |
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** 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
5
(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. |
Exhibit 24
Power of Attorney
Know all by these presents that Kenneth Y. Hao, does hereby make,
constitute and appoint each of Karen M. King and Andrew J. Schader or either one
of them, as a true and lawful attorney-in-fact of the undersigned with full
powers of substitution and revocation, for and in the name, place and stead of
the undersigned (both in the undersigned's individual capacity and as a manager
or member of any limited liability company, as a partner of any partnership, as
an officer of any corporate or other entity, or in the undersigned's capacity in
a position similar to the foregoing at any entity, in each case, for which the
undersigned is otherwise authorized to sign), to execute and deliver such forms
that the undersigned may be required to file with the U.S. Securities and
Exchange Commission as a result of the undersigned's ownership of or
transactions in securities of Broadcom Limited (i) pursuant to Section 16(a) of
the Securities Exchange Act of 1934, as amended, including without limitation,
statements on Form 3, Form 4 and Form 5 (including any amendments thereto) and
(ii) in connection with any applications for EDGAR access codes, including
without limitation the Form ID. The Power of Attorney shall remain in full force
and effect until the undersigned is no longer required to file Forms 3, 4 and 5
with regard to ownership or transactions in securities of Broadcom Limited,
unless earlier revoked in writing. The undersigned acknowledges that Karen M.
King and Andrew J. Schader are not assuming any of the undersigned's
responsibilities to comply with Section 16 of the Securities Exchange Act of
1934.
By: /s/ Kenneth Y. Hao
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Kenneth Y. Hao
Date: February 1, 2016
