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Form 3 Qualtrics International For: Nov 14 Filed by: Stucki Brian

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November 30, 2022 2:44 PM EST
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 *
Stucki Brian
(Last) (First) (Middle)
333 WEST RIVER PARK DRIVE
(Street)
PROVO UT 84604
(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
11/14/2022 		3. Issuer Name and Ticker or Trading Symbol
Qualtrics International Inc. [ XM ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
See Remarks
 5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
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 236,903 (1) (2) (3) (4) (5)
D
 
Class A Common Stock 114,644
D
 
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. Includes an award of restricted stock units ("RSUs") granted on June 10, 2020 under the 2021 Qualtrics International Inc. Employee Omnibus Equity Plan (the "2021 Plan"), of which 5,340 RSUs are currently unvested. Such award vests as to one-third on each of June 10, 2021, June 10, 2022, and June 10, 2023, subject to the Reporting Person's continued service to the Issuer as of each vesting date.
2. Includes an award of RSUs granted on February 1, 2021 under the 2021 Plan, of which 156,251 RSUs are currently unvested. Such award vests as to 25% on the first anniversary of the grant date and ratably thereafter in 16 equal quarterly installments, subject to the Reporting Person's continued service to the Issuer as of each vesting date.
3. Includes an award of RSUs granted on February 1, 2021 under the 2021 Plan, of which 18,844 RSUs are currently unvested. Such award vests in 16 equal quarterly installments, subject to the Reporting Person's continued service to the Issuer as of each vesting date.
4. Includes an award of RSUs granted on August 4, 2021 under the 2021 Plan, of which 25 RSUs are currently unvested. Such award vests as to one-third on each of January 31, 2022, July 29, 2022, and January 31, 2023, subject to the Reporting Person's continued service to the Issuer as of each vesting date.
5. Includes an award of RSUs granted on February 18, 2022 under the 2021 Plan, of which 56,443 RSUs are currently unvested. Such award vests in 16 equal quarterly installments, subject to the Reporting Person's continued service to the Issuer as of each vesting date.
Remarks:
President and Chief Operating Officer.  Exhibit 24 - Power of Attorney.
/s/ Blake Tierney, Attorney-in-Fact 11/30/2022
** 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.

ATTACHMENTS / EXHIBITS

STUCKI POA


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