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