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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 |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
DILLER JAMES C/O AVAGO TECHNOLOGIES US INC. 350 WEST TRIMBLE ROAD SAN JOSE, CA 95131 |
 X |  |  |  |
Patricia H. McCall, Attorney-in-Fact for James Diller | 12/06/2011 | |
**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) | Includes 2,395 restricted share units. Upon vesting thereof, the Reporting Person is entitled to receive one (1) ordinary share for each one (1) restricted stock unit. |
(2) | The James V. Diller and June P. Diller Trust UA 7/20/77 (the "Diller Trust") received 8,767 shares on August 9, 2011 from the June Diller Annuity Trust and 16,869 shares on August 9, 2011 from the James Diller Annuity Trust. |
(3) | Shares held by the June P. Diller Annuity Trust - 2010B dated May 10, 2010 (the "June Diller Annuity Trust") for which the Reporting Person serves as Trustee. |
(4) | Shares held by the James V. Diller Annuity Trust - 2010B dated May 10, 2010 (the "James Diller Annuity Trust") for which the Reporting Person serves as Trustee. |
(5) | Shares held by the Diller Trust for which the Reporting Person serves as Trustee. |