# EDGAR Filing Document

**Accession Number:** 0001747748
**File Stem:** 0001562180-23-001098
**Filing Date:** 2023-2
**Character Count:** 8762
**Document Hash:** ceb408b88787d2915a412632380eed10
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001562180-23-001098.hdr.sgml**: 20230207

**ACCESSION NUMBER**: 0001562180-23-001098

**CONFORMED SUBMISSION TYPE**: 4

**PUBLIC DOCUMENT COUNT**: 2

**CONFORMED PERIOD OF REPORT**: 20230203

**FILED AS OF DATE**: 20230207

**DATE AS OF CHANGE**: 20230207

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Stucki Brian
- **CENTRAL INDEX KEY:** 0001954798

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39952
- **FILM NUMBER:** 23596841

**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

## Ex-24

```

                                                         Exhibit 24

                           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 15th day of November, 2022.

                                       /s/ Brian Stucki
                                       -------------------------
                                         Brian Stucki

```

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

## FORM 4

### 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>Stucki Brian<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>2023-02-03 | **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>_See Remarks_ |
| **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 | 2023-02-03 |  | S |  | 1070.00<sup>(1)</sup> | D | 16.563<sup>(2)</sup> | 471221.00 | D |  |
| Class A Common Stock | 2023-02-03 |  | S |  | 1406.00<sup>(3)</sup> | D | 16.563<sup>(2)</sup> | 469815.00 | 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) Represents shares required to be sold by the Reporting Person to cover tax withholding obligations in connection with the vesting of restricted stock units. These sales were automatic and intended to qualify under Rule 10b5-1.

(2) The price reported in column 4 is a weighted average price. These shares were sold in multiple transactions at prices ranging from $16.47 to $16.75, inclusive. The Reporting Person undertakes to provide to the Issuer, any security holder of the Issuer or the staff of the Securities and Exchange Commission, upon request, full information regarding the number of shares sold at each separate price within the range set forth in this footnote.

(3) Represents shares required to be sold by the Reporting Person to cover tax withholding obligations in connection with the vesting of performance stock units. These sales were automatic and intended to qualify under Rule 10b5-1.

**Remarks:**
President and Chief Operating Officer

**Signature:** /s/ Blake Tierney, Attorney-in-Fact  
**Date:** 2023-02-07

### 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.**