0001562180-21-006336.txt : 20211005 0001562180-21-006336.hdr.sgml : 20211005 20211005204129 ACCESSION NUMBER: 0001562180-21-006336 CONFORMED SUBMISSION TYPE: 4/A PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210201 FILED AS OF DATE: 20211005 DATE AS OF CHANGE: 20211005 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Thimsen John CENTRAL INDEX KEY: 0001842163 FILING VALUES: FORM TYPE: 4/A SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 211308514 MAIL ADDRESS: STREET 1: QUALTRICS INTERNATIONAL INC. STREET 2: 333 WEST RIVER PARK DRIVE CITY: PROVO STATE: UT ZIP: 84604 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 4/A 1 primarydocument.xml PRIMARY DOCUMENT X0306 4/A 2021-02-01 2021-02-02 false 0001747748 Qualtrics International Inc. XM 0001842163 Thimsen John 333 WEST RIVER PARK DRIVE PROVO UT 84604 false true false false Chief Technology Officer Class A Common Stock 2021-02-01 4 A false 288289.00 A 288289.00 D Class A Common Stock 2021-02-01 4 A false 52652.00 A 340941.00 D Class A Common Stock 2021-02-01 4 A false 833333.00 A 1174274.00 D Class A Common Stock 2021-02-01 4 A false 33367.00 A 1207641.00 D On February 2, 2021, the Reporting Person filed a Form 4 erroneously reporting an acquisition of 288,290, instead of 288,289, restricted stock units ("RSUs") with respect to Class A common stock granted to the Reporting Person in exchange for cash-settled restricted stock units with respect to SAP SE stock tendered in the exchange offer in connection with the initial public offering of the Registrant's Class A common stock (the "Exchange Offer"). These RSUs continue to vest in equal annual installments, in accordance with the vesting terms of the original awards that were tendered in the Exchange Offer. Represents RSUs with respect to Class A common stock granted to the Reporting Person in exchange for cash-settled restricted stock units with respect to SAP SE stock tendered in the Exchange Offer. These RSUs continue to vest in equal annual installments, in accordance with the vesting terms of the original awards that were tendered in the Exchange Offer. The Form 4 filed on February 2, 2021 is amended to correct the number of shares beneficially owned following the transaction. Represents RSUs granted under the 2021 Qualtrics International Inc. Employee Omnibus Equity Plan (the "2021 Plan"). These RSUs vest 25% on the first anniversary of the grant date and ratably thereafter in 12 equal quarterly installments. Represents RSUs granted under the 2021 Plan. These RSUs vest in 16 equal quarterly installments. /s/ Blake Tierney, Attorney-in-Fact 2021-10-05