0001562180-23-001953.txt : 20230228 0001562180-23-001953.hdr.sgml : 20230228 20230228160714 ACCESSION NUMBER: 0001562180-23-001953 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230224 FILED AS OF DATE: 20230228 DATE AS OF CHANGE: 20230228 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Johnson Omar CENTRAL INDEX KEY: 0001846291 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 23685185 MAIL ADDRESS: STREET 1: 1950 UNIVERSITY AVENUE, SUITE 350 CITY: PALO ALTO STATE: CA ZIP: 94303 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 2023-02-24 false 0001747748 Qualtrics International Inc. XM 0001846291 Johnson Omar 333 WEST RIVER PARK DRIVE PROVO UT 84604 true false false false Class A Common Stock 2023-02-24 4 A false 9287.00 A 27843.00 D Represents restricted stock units ("RSUs") granted on February 24, 2023 under the 2021 Qualtrics International Inc. Employee Omnibus Equity Plan. These RSUs vest in 12 equal quarterly installments following February 1, 2023, subject to the Reporting Person's continued service to the Issuer on each such date. /s/ Blake Tierney, Attorney-in-Fact 2023-02-28