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