# EDGAR Filing Document

**Accession Number:** 0001747748
**File Stem:** 0001562180-23-000990
**Filing Date:** 2023-2
**Character Count:** 7379
**Document Hash:** b6e35c5c2fa2f7b13f5c069643d3cf5c
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001562180-23-000990.hdr.sgml**: 20230203

**ACCESSION NUMBER**: 0001562180-23-000990

**CONFORMED SUBMISSION TYPE**: 4/A

**PUBLIC DOCUMENT COUNT**: 1

**CONFORMED PERIOD OF REPORT**: 20210201

**FILED AS OF DATE**: 20230203

**DATE AS OF CHANGE**: 20230203

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** McMurray Bill
- **CENTRAL INDEX KEY:** 0001842121

**FILING VALUES:**
- **FORM TYPE:** 4/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39952
- **FILM NUMBER:** 23588009

**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

### UNITED STATES SECURITIES AND EXCHANGE COMMISSION
**Washington, D.C. 20549**

## FORM 4/A

### STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

[ ] Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan for the purchase or sale of equity securities of the issuer that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>McMurray Bill<br><sub>(Last) (First) (Middle)</sub><br>333 WEST RIVER PARK DRIVE<br><sub>(Street)</sub><br>PROVO, UT 84604<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2021-02-01 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [ ] 10% Owner<br>[X] Officer (give title below) [ ] Other (specify below)<br>_Chief Revenue Officer_ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Qualtrics International Inc. [ XM ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[X] Form filed by One Reporting Person<br>[ ] Form filed by More than One Reporting Person |

---

## Table I - Non-Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | 3. Transaction Code (V) | 3. Transaction Code (V) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | Code | V | Amount | (A) or (D) | Price | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| Class A Common Stock | 2021-02-01 |  | A |  | 78980.00<sup>(1)</sup> | A | <sup>(1)</sup> | 78980.00 | D |  |
| Class A Common Stock | 2021-02-01 |  | A |  | 48067.00<sup>(2)</sup> | A | <sup>(2)</sup> | 127047.00 | D |  |
| Class A Common Stock | 2021-02-01 |  | A |  | 333333.00<sup>(3)</sup> | A | <sup>(3)</sup> | 460380.00 | D |  |
| Class A Common Stock | 2021-02-01 |  | A |  | 66667.00<sup>(4)</sup> | A | <sup>(4)</sup> | 527047.00<sup>(5)</sup> | D |  |

---

## Table II - Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | 4. Transaction Code (V) | 4. Transaction Code (V) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 6. Date Exercisable and Expiration Date | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Underlying Securities | 7. Title and Amount of Underlying Securities | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |

---

### Footnotes:

(1) On February 2, 2021, the Reporting Person filed a Form 4 erroneously reporting an acquisition of 78,981, instead of 78,980, restricted stock units ("RSUs") with respect to Class A common stock granted to the Reporting Person in exchange for cash-settled restricted stock units with respect to SAP SE stock tendered in the exchange offer in connection with the initial public offering of the Registrant's Class A common stock (the "Exchange Offer"). These RSUs continue to vest in equal annual installments, in accordance with the vesting terms of the original awards that were tendered in the Exchange Offer. The overstatement was carried forward on the Reporting Person's subsequently filed Forms 4.

(2) Represents RSUs with respect to Class A common stock granted to the Reporting Person in exchange for cash-settled restricted stock units withrespect to SAP SE stock tendered in the Exchange Offer. These RSUs continue to vest in equal annual installments, in accordance with the vesting terms of the original awards that were tendered in the Exchange Offer.

(3) Represents 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.

(4) Represents RSUs granted under the 2021 Plan. These RSUs vest in 16 equal quarterly installments.

(5) The Form 4 filed on February 2, 2021 is amended to correct the number of shares beneficially owned following the transaction.

**Signature:** /s/ Blake Tierney, Attorney-in-Fact  
**Date:** 2023-02-03

### Remarks:

Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.

* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).

** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).

Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.

**Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.**