0001562180-22-001852.txt : 20220223 0001562180-22-001852.hdr.sgml : 20220223 20220223203119 ACCESSION NUMBER: 0001562180-22-001852 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220218 FILED AS OF DATE: 20220223 DATE AS OF CHANGE: 20220223 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Anderson Brad R. CENTRAL INDEX KEY: 0001892442 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 22665988 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 1 primarydocument.xml PRIMARY DOCUMENT X0306 4 2022-02-18 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 2022-02-18 4 A false 150515.00 A 482090.00 D Represents restricted stock units ("RSUs") granted on February 18, 2022 under the 2021 Qualtrics International Inc. Employee Omnibus Equity Plan. These RSUs vest in 16 equal quarterly installments following February 1, 2022, subject to the Reporting Person's continued service to the Issuer on each such date. Reflects the correction of immaterial errors in Column 5 reported in the Reporting Person's Form 4/A filed on February 11, 2022. /s/ Blake Tierney, Attorney-in-Fact 2022-02-23