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