0001562180-22-003473.txt : 20220419 0001562180-22-003473.hdr.sgml : 20220419 20220419172300 ACCESSION NUMBER: 0001562180-22-003473 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220418 FILED AS OF DATE: 20220419 DATE AS OF CHANGE: 20220419 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Serafin Zig CENTRAL INDEX KEY: 0001758334 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 22835688 MAIL ADDRESS: STREET 1: 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 2022-04-18 false 0001747748 Qualtrics International Inc. XM 0001758334 Serafin Zig 333 WEST RIVER PARK DRIVE PROVO UT 84604 true true false false Chief Executive Officer Class A Common Stock 2022-04-18 4 F false 62984.00 26.07 D 12117883.00 D 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. /s/ Blake Tierney, Attorney-in-Fact 2022-04-19