0000899243-21-005938.txt : 20210211 0000899243-21-005938.hdr.sgml : 20210211 20210211163819 ACCESSION NUMBER: 0000899243-21-005938 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210201 FILED AS OF DATE: 20210211 DATE AS OF CHANGE: 20210211 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Silver Lake Group, L.L.C. CENTRAL INDEX KEY: 0001418226 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 21620310 BUSINESS ADDRESS: STREET 1: 2775 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 6502338120 MAIL ADDRESS: STREET 1: 2775 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SLTA VI (GP), L.L.C. CENTRAL INDEX KEY: 0001830356 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 21620311 BUSINESS ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 650-233-8120 MAIL ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Silver Lake Technology Associates VI, L.P. CENTRAL INDEX KEY: 0001830249 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 21620312 BUSINESS ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 650-233-8120 MAIL ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SLP VI Aggregator GP, L.L.C. CENTRAL INDEX KEY: 0001830259 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 21620313 BUSINESS ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 650-233-8120 MAIL ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SLP Quartz Aggregator, L.P. CENTRAL INDEX KEY: 0001841116 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 21620314 BUSINESS ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 650-233-8120 MAIL ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2776 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Durban Egon CENTRAL INDEX KEY: 0001651403 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 21620315 MAIL ADDRESS: STREET 1: C/O SILVER LAKE STREET 2: 2775 SAND HILL ROAD, SUITE 100 CITY: MENLO PARK STATE: CA ZIP: 94025 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Qualtrics International Inc. CENTRAL INDEX KEY: 0001747748 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-PREPACKAGED SOFTWARE [7372] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 333 WEST RIVER PARK DRIVE CITY: PROVO STATE: UT ZIP: 84604 BUSINESS PHONE: 385-203-4999 MAIL ADDRESS: STREET 1: 333 WEST RIVER PARK DRIVE CITY: PROVO STATE: UT ZIP: 84604 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2021-02-01 0 0001747748 Qualtrics International Inc. XM 0001418226 Silver Lake Group, L.L.C. C/O SILVER LAKE 2775 SAND HILL ROAD, SUITE 100 MENLO PARK CA 94025 1 0 1 0 0001830356 SLTA VI (GP), L.L.C. C/O SILVER LAKE 2775 SAND HILL ROAD, SUITE 100 MENLO PARK CA 94025 1 0 1 0 0001830249 Silver Lake Technology Associates VI, L.P. C/O SILVER LAKE 2775 SAND HILL ROAD, SUITE 100 MENLO PARK CA 94025 1 0 1 0 0001830259 SLP VI Aggregator GP, L.L.C. C/O SILVER LAKE 2775 SAND HILL ROAD, SUITE 100 MENLO PARK CA 94025 1 0 1 0 0001841116 SLP Quartz Aggregator, L.P. C/O SILVER LAKE 2775 SAND HILL ROAD, SUITE 100 MENLO PARK CA 94025 1 0 1 0 0001651403 Durban Egon C/O SILVER LAKE 2775 SAND HILL ROAD, SUITE 100 MENLO PARK CA 94025 1 0 0 0 Class A Common Stock 22518484 I Held through SLP Quartz Aggregator, L.P. This Form 3 is filed by SLP Quartz Aggregator, L.P. ("SLP Quartz"), SLP VI Aggregator GP, L.L.C. ("SLP VI GP"), Silver Lake Technology Associates VI, L.P. ("SLTA VI"), SLTA VI (GP), L.L.C. ("SLTA VI GP"), Silver Lake Group, L.L.C. ("SLG") and Mr. Egon Durban. Mr. Egon Durban serves as a member of the board of directors of Qualtrics International Inc. (the "Issuer") and is Co-CEO and Managing Member of SLG. Each of SLP Quartz, SLP VI GP, SLTA VI, SLTA VI GP and SLG may be deemed to be a director by deputization of the Issuer. Represents securities held by SLP Quartz. SLP VI GP is the general partner of SLP Quartz. SLTA VI is the managing member of SLP VI GP. SLTA VI GP is the general partner of SLTA VI. SLG is the managing member of SLTA VI GP. The Class A Common Stock beneficially owned and reported herein represents approximately 4.4% of the total common stock of the Issuer as of the date of filing. The Reporting Persons are jointly filing this Form 3 pursuant to Rule 16a-3(j) under the Exchange Act. This filing shall not be deemed an admission that the Reporting Persons are beneficial owners of all securities covered by this filing for purposes of Section 16 of the Exchange Act or otherwise, and each Reporting Person disclaims beneficial ownership of these securities, except to the extent of such Reporting Person's pecuniary interest therein, if any. By: /s/ Andrew J. Schader, Managing Director and General Counsel of Silver Lake Group, L.L.C. 2021-02-11 By: /s/ Andrew J. Schader, Managing Director and General Counsel of Silver Lake Group, L.L.C., managing member of SLTA VI (GP), L.L.C. 2021-02-11 By: /s/ Andrew J. Schader, Managing Director and General Counsel of Silver Lake Group, L.L.C., managing member of SLTA VI (GP), L.L.C., general partner of Silver Lake Technology Associates VI, L.P. 2021-02-11 By: /s/ Andrew J. Schader, Managing Director and General Counsel of Silver Lake Group, L.L.C., managing member of SLTA VI (GP), L.L.C., general partner of Silver Lake Technology Associates VI, L.P., managing member of SLP VI Aggregator GP, L.L.C. 2021-02-11 By: /s/ Andrew J. Schader, Managing Director and GC of Silver Lake Group, L.L.C., managing member of SLTA VI (GP), L.L.C., GP of Silver Lake Technology Associates VI, L.P., managing member of SLP VI Aggregator GP, L.L.C., GP of SLP Quartz Aggregator, L.P. 2021-02-11 /s/ Egon Durban 2021-02-11