0001562180-23-001004.txt : 20230203 0001562180-23-001004.hdr.sgml : 20230203 20230203200221 ACCESSION NUMBER: 0001562180-23-001004 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230201 FILED AS OF DATE: 20230203 DATE AS OF CHANGE: 20230203 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: 23588071 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: 471754215 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 2023-02-01 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 2023-02-01 4 A false 59654.00 A 600301.00 D Represents the number of performance stock units ("PSUs") granted under the 2021 Qualtrics International Inc. Employee Omnibus Equity Plan which vested on February 1, 2023. The extent to which these PSUs vest is conditional upon the achievement of objectives set and approved by the Board. To the extent these objectives are met on an annual basis, these PSUs vest 25% on the first anniversary of the grant date and ratably thereafter in 3 equal annual installments. /s/ Blake Tierney, Attorney-in-Fact 2023-02-03