0001562180-22-000989.txt : 20220202 0001562180-22-000989.hdr.sgml : 20220202 20220202215847 ACCESSION NUMBER: 0001562180-22-000989 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20220131 FILED AS OF DATE: 20220202 DATE AS OF CHANGE: 20220202 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Anderson Brad R. CENTRAL INDEX KEY: 0001892442 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39952 FILM NUMBER: 22586324 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 4 1 primarydocument.xml PRIMARY DOCUMENT X0306 4 2022-01-31 false 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 2022-01-31 4 A false 500.00 24.88 A 334360.00 D Class A Common Stock 2022-01-31 4 F false 17.00 29.27 D 334343.00 D Class A Common Stock 2022-01-31 4 F false 8.00 29.27 D 334335.00 D Represents shares acquired under the 2021 Qualtrics International Inc. Employee Stock Purchase Plan. Represents shares of Class A common stock withheld by the Issuer in satisfaction of tax withholding obligations in connection with the purchase of shares under the 2021 Qualtrics International Inc. Employee Stock Purchase Plan. Such withholding is mandated by an election of the Issuer made in advance and does not represent a discretionary trade by the Reporting Person. 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. Exhibit 24 - Power of Attorney /s/ Blake Tierney, Attorney-in-Fact 2022-02-02 EX-24 2 bandersonpoa.txt BRAD POA POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS that the undersigned hereby constitutes and appoints Zig Serafin, Chris Beckstead, Blake Tierney and Rob Bachman to be his or her true and lawful attorney-in-fact and agent to execute and file for and on behalf of the undersigned (i) any reports on Forms 3, 4, 5 and, if applicable, 144 (including any amendments thereto and any successors to such Forms) with respect to ownership of securities of Qualtrics International Inc. (the "Company") that the undersigned may be required to file with the Securities and Exchange Commission in accordance with Section 16(a) of the Securities Exchange Act of 1934 and the rules thereunder and/or Rule 144 under the Securities Act of 1933, and (ii) as necessary, any other documents necessary or appropriate to obtain codes and passwords enabling the undersigned to file such reports electronically. The undersigned acknowledges that the foregoing attorney-in- fact, in serving in such capacity at the request of the undersigned, is not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934 and/or Rule 144 under the Securities Act of 1933. This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4, 5 and, if applicable, 144 with respect to the undersigned's holdings and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorney-in-fact. This Power of Attorney also serves to revoke and replace as of the date hereof, any prior Power of Attorney executed by the undersigned with respect to the ownership of securities of the Company. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 1st day of November, 2021. /s/ Brad R. Anderson Brad R. Anderson Exhibit 24