SEC Form 3
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*
SAP SE

(Last) (First) (Middle)
DIETMAR-HOPP-ALLEE 16

(Street)
WALLDORF 2M 69190

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
01/28/2021
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)
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
Class B Common Stock (1) (1) Class A Common Stock 423,170,610 (1) I See Footnote(2)
1. Name and Address of Reporting Person*
SAP SE

(Last) (First) (Middle)
DIETMAR-HOPP-ALLEE 16

(Street)
WALLDORF 2M 69190

(City) (State) (Zip)
1. Name and Address of Reporting Person*
SAP America, Inc.

(Last) (First) (Middle)
3999 WEST CHESTER PIKE

(Street)
NEWTOWN SQUARE PA 19073

(City) (State) (Zip)
Explanation of Responses:
1. Converts into Class B Common Stock upon the election of the holder on a one-for-one basis.
2. These shares of Class B Common Stock are held by SAP America, Inc., a wholly-owned subsidiary of SAP SE.
Remarks:
/s/ Luka Mucic, Authorized Signatory of SAP SE 01/28/2021
/s/ Michael Ploetner, Authorized Signatory of SAP SE 01/28/2021
/s/ Mary Beth Hanss, Authorized Signatory of SAP America, Inc. 01/28/2021
** 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 5 (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.
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