Initial Statement of Beneficial Ownership (3)
November 09 2021 - 5:46PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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
*
Pegels Kevin Carl |
2. Date of Event Requiring Statement (MM/DD/YYYY)
11/2/2021
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3. Issuer Name and Ticker or Trading Symbol
ILLUMINA, INC. [ILMN]
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(Last)
(First)
(Middle)
5200 ILLUMINA WAY |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) Chief of Global Operations / |
(Street)
SAN DIEGO, CA 92122
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 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 Beneficially Owned
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1.Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock (1) | 5419 | D | |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 4) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Performance Shares (2) | (3) | 1/2/2022 | Common Stock | 1065 | (3) | D | |
Performance Shares (2) | (4) | 1/1/2023 | Common Stock | 1166 | (4) | D | |
Performance Shares (2) | (5) | 12/31/2023 | Common Stock | 1104 | (5) | D | |
Explanation of Responses: |
(1) | Includes unvested Restricted Stock Units granted prior to appointment as Section 16 Officer. |
(2) | Granted prior to appointment as Section 16 Officer. |
(3) | Each performance stock unit represents a contingent right to receive one share of common stock based on the Company's earnings per share for the fiscal year ending January 2, 2022. The number of shares issued will range from 0% to 150% of the amount specified above, based on the company's actual earnings per share for the fiscal year ending January 2, 2022, relative to pre-defined objectives, subject to awardee's continuing status as a service provider on such dates. |
(4) | Each performance stock unit represents a contingent right to receive one share of common stock based on the Company's earnings per share for the fiscal year ending January 1, 2023. The number of shares issued will range from 0% to 150% of the amount specified above, based on the company's actual earnings per share for the fiscal year ending January 1, 2023, relative to pre-defined objectives, subject to awardee's continuing status as a service provider on such dates. |
(5) | Each performance stock unit represents a contingent right to receive one share of common stock based on the Company's earnings per share for the fiscal year ending December 31, 2023. The number of shares issued will range from 0% to 175% of the amount specified above, based on the Company's actual earnings per share for the fiscal year ending December 31,2023, relative to pre-defined objectives, subject to awardee's continuing to be a service provider on such dates. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Pegels Kevin Carl 5200 ILLUMINA WAY SAN DIEGO, CA 92122 |
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| Chief of Global Operations |
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Signatures
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By: Robert Maynes for Kevin Pegels | | 11/9/2021 |
**Signature of Reporting Person | Date |
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