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