Form 3 Qualtrics International For: May 13 Filed by: Silver Lake Partners VI DE (AIV), L.P.

May 17, 2021 9:14 PM EDT

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FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person *
Silver Lake Partners VI DE (AIV), L.P.

(Last) (First) (Middle)
C/O SILVER LAKE
2775 SAND HILL ROAD, SUITE 100

(Street)
MENLO PARK CA 94025

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
05/13/2021
3. Issuer Name and Ticker or Trading Symbol
Qualtrics International Inc. [ XM ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Class A Common Stock 111,120
I
Held through Silver Lake Partners VI DE (AIV), L.P. (1) (3) (4)
Class A Common Stock 8,880
I
Held through Silver Lake Technology Investors VI, L.P. (2) (3) (4)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Explanation of Responses:
1. Represents securities held by Silver Lake Partners VI DE (AIV), L.P. ("SLP VI")
2. Represents securities held by Silver Lake Technology Investors VI, L.P. ("SLTI VI")
3. Silver Lake Technology Associates VI, L.P. ("SLTA VI") is the general partner of each of SLP VI and STLI VI. SLTA VI (GP), L.L.C. ("SLTA VI GP") is the general partner of SLTA VI. Silver Lake Group, L.L.C. ("SLG") is the managing member of SLTA VI GP. Mr. Egon Durban serves as a member of the board of directors of Qualtrics International Inc. (the "Issuer") and is Co-CEO and a Managing Member of SLG. Each of SLP VI, SLTI VI, SLTA VI, SLTA VI GP and SLG may be deemed to be a director by deputization of the Issuer.
4. Not included on this Form 3 are an additional 22,518,484 shares of Class A Common Stock held by SLP Quartz Aggregator, L.P., an affiliate of the Reporting Persons. SLTA, STLA GP, SLG and Mr. Egon Durban have separately filed a Form 4 in connection with the acquisition of the shares of Class A Common Stock described in this Form.
Remarks:
The Reporting Persons are jointly filing this Form 3 pursuant to Rule 16a-3(j) under the Exchange Act.  This filing shall not be deemed an admission that the Reporting Persons are beneficial owners of all securities covered by this filing for purposes of Section 16 of the Exchange Act or otherwise, and each Reporting Person disclaims beneficial ownership of these securities, except to the extent of such Reporting Person's pecuniary interest therein, if any.
By: /s/ Egon Durban, Co-CEO of Silver Lake Group, L.L.C., managing member of SLTA VI (GP), L.L.C., general partner of Silver Lake Technology Associates VI, L.P., general partner of Silver Lake Partners VI DE (AIV), L.P. 05/17/2021
** Signature of Reporting Person Date
By: /s/ Egon Durban, Co-CEO of Silver Lake Group, L.L.C., managing member of SLTA VI (GP), L.L.C., GP of Silver Lake Technology Associates VI, L.P., general partner of Silver Lake Technology Investors VI, L.P. 05/17/2021
** Signature of Reporting Person Date
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.


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