0001562180-23-001002.txt : 20230203 0001562180-23-001002.hdr.sgml : 20230203 20230203200117 ACCESSION NUMBER: 0001562180-23-001002 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230201 FILED AS OF DATE: 20230203 DATE AS OF CHANGE: 20230203 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: 23588064 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: 471754215 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 2023-02-01 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 2023-02-01 4 A false 1500000.00 A 12496949.00 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, 2023. 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. /s/ Blake Tierney, Attorney-in-Fact 2023-02-03