0001562180-23-005539.txt : 20230628 0001562180-23-005539.hdr.sgml : 20230628 20230628210758 ACCESSION NUMBER: 0001562180-23-005539 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230628 FILED AS OF DATE: 20230628 DATE AS OF CHANGE: 20230628 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: 231053996 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: 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 X0407 4 2023-06-28 true 0001747748 Qualtrics International Inc. XM 0001892442 Anderson Brad R. 333 WEST RIVER PARK DRIVE PROVO UT 84604 false true false false President, Products & Services false Class A Common Stock 2023-06-28 4 D false 656143.00 D 0.00 D Pursuant to the Agreement and Plan of Merger, dated March 12, 2023 (the "Merger Agreement"), by and among Qualtrics International Inc., a Delaware corporation ("Issuer"), Quartz Holdco, LLC, a Delaware limited liability company ("Parent") and Quartz MergerCo, Inc., a Delaware corporation and a wholly owned subsidiary of Parent ("Merger Sub"), on June 28, 2023, Merger Sub merged with and into Issuer, with Issuer surviving the merger as a wholly owned subsidiary of Parent (the "Merger"). At the effective time of the Merger (the "Effective Time"), each then outstanding share of Issuer Class A common stock, par value $0.0001 per share ("Class A Common Stock") and Issuer Class B common stock, par value $0.0001 per share ("Class B Common Stock" and together with Class A Common Stock, "Common Stock"), other than the Excluded Shares (as defined in the Merger Agreement) was cancelled, ceased to exist and automatically converted into the right to receive $18.15 in cash, without interest and after giving effect to any applicable withholding taxes. These shares include restricted stock units of Issuer (each, an "RSU") and performance stock units of Issuer (each, a "PSU"). Each RSU and PSU that, as of immediately prior to the Effective Time, was vested in accordance with its terms after giving effect to any vesting that occurred as a result of the transactions in connection with the Merger but had not yet been settled (each, a "Vested RSU" and "Vested PSU," respectively), was cancelled as of the Effective Time and converted into the right to receive an amount in cash, without interest, equal to the product of $18.15 and the aggregate number of shares of Common Stock subject to such Vested RSU or Vested PSU, as applicable, less applicable taxes and authorized deductions. Each RSU that, as of immediately prior to the Effective Time, was not a Vested RSU (each, an "Unvested RSU") was converted into the contingent right to receive an amount in cash equal to the product of $18.15 and the aggregate number of shares of Common Stock subject to such Unvested RSU (the "Unvested RSU Consideration"). Subject to the Reporting Person's continued service with Issuer and its subsidiaries through the applicable vesting dates, such Unvested RSU Consideration will vest and become payable at the same time as the underlying Unvested RSU would have vested and become payable pursuant to its terms and will otherwise generally remain subject to the same terms and conditions as applied to the underlying Unvested RSU immediately prior to the Effective Time. Each PSU that, as of immediately prior to the Effective Time, was not a Vested PSU (each, an "Unvested PSU") was converted into the contingent right to receive an amount in cash equal to the product of $18.15 and the aggregate number of shares of Common Stock subject to such Unvested PSU based on the attainment of the applicable performance metrics at the target level of performance (the "Unvested PSU Consideration"). (Continued from Footnote 5) Subject to the Reporting Person's continued service with Issuer and its subsidiaries through the applicable time-based vesting dates, such Unvested PSU Consideration will vest and become payable at the same time as the underlying Unvested PSU would have vested and become payable pursuant to its terms and will otherwise generally remain subject to the same terms and conditions as applied to the underlying Unvested PSU immediately prior to the Effective Time, except that no performance-based vesting metrics or criteria will apply from and after the Effective Time. /s/ Blake Tierney, Attorney-in-Fact 2023-06-28