0001562180-21-005159.txt : 20210804 0001562180-21-005159.hdr.sgml : 20210804 20210804154017 ACCESSION NUMBER: 0001562180-21-005159 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210802 FILED AS OF DATE: 20210804 DATE AS OF CHANGE: 20210804 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Smith Ryan S CENTRAL INDEX KEY: 0001842748 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 211143798 MAIL ADDRESS: STREET 1: 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 2021-08-02 false 0001747748 Qualtrics International Inc. XM 0001842748 Smith Ryan S 333 WEST RIVER PARK DRIVE PROVO UT 84604 true true false false Founder and Executive Chair Class A Common Stock 2021-08-02 4 F false 71839.00 41.73 D 13536068.00 D Class A Common Stock 6000000.00 I By Q II, LLC 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. Includes 500 shares acquired under the 2021 Qualtrics International Inc. Employee Stock Purchase Plan on July 31, 2021. /s/ Blake Tierney, Attorney-in-Fact 2021-08-04