0001562180-21-006340.txt : 20211005
0001562180-21-006340.hdr.sgml : 20211005
20211005204208
ACCESSION NUMBER: 0001562180-21-006340
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20211001
FILED AS OF DATE: 20211005
DATE AS OF CHANGE: 20211005
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Bachman Robert W
CENTRAL INDEX KEY: 0001842759
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39952
FILM NUMBER: 211308519
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
2021-10-01
false
0001747748
Qualtrics International Inc.
XM
0001842759
Bachman Robert W
333 WEST RIVER PARK DRIVE
PROVO
UT
84604
false
true
false
false
Chief Financial Officer
Class A Common Stock
2021-10-01
4
F
false
3230.00
43.88
D
508224.00
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.
This total amount has been updated to reflect transactions that were inadvertently omitted and have been subsequently filed on a Form 4.
/s/ Blake Tierney, Attorney-in-Fact
2021-10-05