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 NXP SEMICONDUCTORS N.V. |
| HIGH TECH CAMPUS 60 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
08/01/2019
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3. Issuer Name and Ticker or Trading Symbol
NXP Semiconductors N.V.
[ NXPI ]
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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)
| X |
Form filed by One Reporting Person |
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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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| Common Stock |
0 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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 |
| Explanation of Responses: |
| Remarks: |
|
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/s/ Jasmin Staiblin by Dr. Jean A.W. Schreurs under Power of Attorney |
08/01/2019 |
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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. |
Power of Attorney
I, the undersigned, hereby appoint Jennifer Wuamett, Jean Schreurs, and Timothy Shelhamer, and each of them, acting alone
without the other, my true and lawful attorneys-in-fact, with full power of substitution and revocation, to prepare,
execute and file on my behalf with respect to my holdings of and transactions in securities issued by NXP Semiconductors
N.V. (the "Company"):
* any and all Forms 3, 4, 5 and 144 and any successor forms (and any amendments or corrections to all such forms); and
* any related documents or items (including a Form ID and any other documents necessary to obtain codes and passwords
necessary to make electronic filings) which any one of them may deem needed or desirable with the Securities and Exchange
Commission and any and all applicable stock exchanges.
In addition, I hereby grant unto said attorneys-in-fact full power and authority to do and perform each and every act
and thing necessary or appropriate in connection with the foregoing which, in the opinion of such attorney-in-fact,
may be of benefit to, in the best interest of, or legally required, by me. I hereby ratify and confirm all that said
attorneys-in-fact, or their substitute or substitutes, may lawfully do or cause to be done by virtue of this power of
attorney and the rights and powers granted herein.
I acknowledge that this Power of Attorney authorizes, but does not require, each such attorney-in-fact to act in his or
her discretion on information provided to such attorney-in-fact without independent verification of such information, and
this Power of Attorney does not relieve me from responsibility for complying with Section 16(a) of the Securities Exchange
Act of 1934, as amended. This Power of Attorney shall remain in full force and effect until revoked by delivering a
signed Revocation of Power of Attorney to each of the foregoing attorneys-in-fact.
The undersigned agrees that each attorney-in-fact may rely entirely on information furnished orally or in writing by the
undersigned to such attorney-in-fact. The undersigned also agrees to indemnify and hold harmless the Company and each
attorney-in-fact against any losses, claims, damages or liabilities that arise out of or are based upon any untrue
statements or omission of necessary facts in the information provided by the undersigned to such attorney-in-fact for
purposes of executing, acknowledging, delivering or filing Forms 3, 4, 5 or 144 (including amendments thereto) or Form ID,
and agrees to reimburse the Company and such attorney-in-fact for any legal or other expenses reasonably incurred in
connection with investigating or defending against any such loss, claim, damage or liability.
This Power of Attorney supersedes any power of attorney previously executed by the undersigned in connection with matters
substantially similar to those discussed herein, and any and all other previous powers of attorney are hereby revoked.
By: /s/ Jasmin Staiblin
Name: Jasmin Staiblin
Date: 17.7.2019
