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