Statement of Changes in Beneficial Ownership (4)
15 June 2019 - 7:30AM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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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1. Name and Address of Reporting Person
*
SEENDRIPU KISHORE
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2. Issuer Name
and
Ticker or Trading Symbol
MAXLINEAR INC
[
MXL
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chairman, President and CEO
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(Last)
(First)
(Middle)
C/O MAXLINEAR, INC., 5966 LA PLACE COURT, SUITE 100
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3. Date of Earliest Transaction
(MM/DD/YYYY)
5/30/2019
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(Street)
CARLSBAD, CA 92008
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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5/30/2019
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G
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V
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805622
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D
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$0
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1320370
(1)
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I
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See footnote
(2)
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Common Stock
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5/30/2019
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G
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V
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805622
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A
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$0
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805622
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I
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See footnote
(3)
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Common Stock
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5/30/2019
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G
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V
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805622
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D
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$0
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514748
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I
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See footnote
(2)
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Common Stock
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5/30/2019
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G
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V
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805622
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A
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$0
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805622
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I
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See footnote
(4)
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Common Stock
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6/11/2019
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G
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V
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426477
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D
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$0
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582064
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I
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See footnote
(5)
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Common Stock
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6/11/2019
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G
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V
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426477
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A
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$0
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941225
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I
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See footnote
(2)
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Common Stock
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6/11/2019
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G
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V
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426477
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D
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$0
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582064
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I
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See footnote
(6)
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Common Stock
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6/11/2019
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G
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V
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426477
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A
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$0
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1367702
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I
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See footnote
(2)
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Common Stock
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18920
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I
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See footnote
(7)
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Common Stock
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12466
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D
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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 Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(1)
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Excludes an aggregate of 2,017,082 shares that were included in prior Forms 4 as part of the end of period holdings of the Seendripu Family Trust dated 10/5/09 (the "Family Trust"). Of these 2,017,082 shares, 1,008,541 shares are held by the Kishore V. Seendripu 2018 Annuity Trust dated May 12, 2018 and 1,008,541 shares are held by the Rekha S. Seendripu 2018 Annuity Trust dated May 12, 2018 (together, the "2018 Annuity Trusts"). On May 30, 2018, the Family Trust transferred 1,008,541 shares to each of the 2018 Annuity Trusts for no consideration.
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(2)
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Shares held by the Seendripu Family Trust dated 10/5/09, a trust for the benefit of the Reporting Person and the Reporting Person's spouse, for which the Reporting Person and the Reporting Person's spouse serve as trustees.
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(3)
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Shares held by the Kishore V. Seendripu 2019 Annuity Trust dated May 6, 2019, a grantor retained annuity trust, for which the Reporting Person serves as trustee.
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(4)
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Shares held by the Rekha S. Seendripu 2019 Annuity Trust dated May 6, 2019, a grantor retained annuity trust, for which the Reporting Person serves as trustee.
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(5)
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Shares held by the Kishore V. Seendripu 2018 Annuity Trust dated May 12, 2018, a grantor retained annuity trust, for which the Reporting Person serves as trustee.
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(6)
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Shares held by the Rekha S. Seendripu 2018 Annuity Trust dated May 12, 2018, a grantor retained annuity trust, for which the Reporting Person serves as trustee.
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(7)
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Shares held by the Seendripu Relatives Trust dated 10/5/09, a trust for the benefit of the Reporting Person's parents and siblings, and for which the Reporting Person serves as trustee.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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SEENDRIPU KISHORE
C/O MAXLINEAR, INC.
5966 LA PLACE COURT, SUITE 100
CARLSBAD, CA 92008
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X
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X
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Chairman, President and CEO
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Signatures
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/s/ Connie Kwong, as Attorney-in-Fact
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6/14/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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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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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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