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