0001562180-21-007044.txt : 20211115 0001562180-21-007044.hdr.sgml : 20211115 20211115160703 ACCESSION NUMBER: 0001562180-21-007044 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211108 FILED AS OF DATE: 20211115 DATE AS OF CHANGE: 20211115 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Anderson Brad R. CENTRAL INDEX KEY: 0001892442 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 211410440 MAIL ADDRESS: STREET 1: C/O 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 3 1 primarydocument.xml PRIMARY DOCUMENT X0206 3 2021-11-08 0 0001747748 Qualtrics International Inc. XM 0001892442 Anderson Brad R. 333 WEST RIVER PARK DRIVE PROVO UT 84604 false true false false President, Products & Services Class A Common Stock 333333.00 D Class A Common Stock 75.00 D Class A Common Stock 452.00 D Represents restricted stock units ("RSUs") granted under the 2021 Qualtrics International Inc. Employee Omnibus Equity Plan (the "2021 Plan"). These RSUs vest 25% on the first anniversary of the grant date and ratably thereafter in 12 equal quarterly installments, subject to the Reporting Person's continued service to the Issuer as of each vesting date. Represents RSUs granted under the 2021 Plan. One third of these RSUs vest on each of February 1, 2022, August 1, 2022, and February 1, 2023, subject to the Reporting Person's continued service to the Issuer as of each vesting date. Exhibit 24 - Power of Attorney /s/ Blake Tierney, Attorney-in-Fact 2021-11-15