0001562180-22-001359.txt : 20220211 0001562180-22-001359.hdr.sgml : 20220211 20220211124956 ACCESSION NUMBER: 0001562180-22-001359 CONFORMED SUBMISSION TYPE: 4/A PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220201 FILED AS OF DATE: 20220211 DATE AS OF CHANGE: 20220211 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Anderson Brad R. CENTRAL INDEX KEY: 0001892442 FILING VALUES: FORM TYPE: 4/A SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 22618757 MAIL ADDRESS: STREET 1: C/O 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 2022-02-01 2022-02-03 false 0001747748 Qualtrics International Inc. XM 0001892442 Anderson Brad R. 333 WEST RIVER PARK DRIVE PROVO UT 84604 false true false false President, Products & Services Class A Common Stock 2022-02-01 4 A false 41666.00 A 373241.00 D Class A Common Stock 2022-02-01 4 F false 28030.00 30.05 D 345211.00 D Class A Common Stock 2022-02-01 4 F false 16396.00 30.05 D 328815.00 D Represents the number of performance stock units ("PSUs") granted under the 2021 Qualtrics International Inc. Employee Omnibus Equity Plan which vested on February 1, 2022. The extent to which these PSUs vest is conditional upon the achievement of objectives set and approved by the Board. To the extent these objectives are met on an annual basis, these PSUs vest 25% on the first anniversary of the grant date and ratably thereafter in 3 equal annual installments. Represents shares of Class A common stock withheld by the Issuer in satisfaction of tax withholding obligations in connection with the vesting of restricted stock units previously granted to the Reporting Person. Such withholding is mandated by an election of the Issuer made in advance and does not represent a discretionary trade by the Reporting Person. Represents shares of Class A common stock withheld by the Issuer in satisfaction of tax withholding obligations in connection with the vesting of performance stock units previously granted to the Reporting Person. Such withholding is mandated by an election of the Issuer made in advance and does not represent a discretionary trade by the Reporting Person. /s/ Blake Tierney, Attorney-in-Fact 2022-02-11