Form 3921 Exercise of an Incentive Stock Option Under Section 422(

1 of

Add "and" before
ZIP code and
remove "comma (,)
and telephone no."
after ZI P code
Iincrease font size I

[J

2525

010

["]

CORRECTED
1 Oat" option wanted

TR/INSFEROR'S name, street address, city. state, ZIP COdeta",Hel€ p k*le-'_'

2 Date option "xercisfJrJ

TRANSfEROR'S federal identification number

I

3 EX(Jfcise price per share

TRANSFf.:REE"S identification number

$

TRANSFEREE'S name

\

(Rev. December 2008)
~45-XXXX

Exercise of
A Qualified $../
392P/ /\Incentive Stock ani
Option Under
~ev;-Apfi!--f'OOg.}
Section '" "' ....... 422(b )1
"r-/Le. m/l.e. vlper!l
4 fair ,M'inkel :lalu~{fMV-U:
Copy A
share or exercise date

OMf3

i~orm

I

$

5 No.

o shares Uanfu~ed

&-¥e6f-ejl"tif",'e>ffiR~

Ishade this box
Street addn,ss (includin(J apt. no.i

City, state, and

I~CCOlJnt

ZiP

code

number (see instructions)

-.I"

3921

/

I

For
Internal Revenue

Service Center

File with Form 1096.

For Privacy Act
and Paperwork
Reduction Act
Notice, see the

2009 General
Instructions for
3921, I .
39) )
Forms 1099, 1098,A 3922,/
5498, and W-2G.

I

I

""-­

Cat. No, 41'1790

Do NO;rut or Separate Forms on This Page

(Rev, December200Sy

"m" '''''':\ C>N "

corporation
whose
stock is being transferre
"h"
TRANseEROR

Ichange 7 to 6
Form

'h"

I

-

Depar:"18nt of tl18 ""masury - Intcmal Revenue Service

Do Not Cut or Separate

rms on This Page

remove 3rd "s" on
address, add
comma (.) after
"address"

'7

of

Add "and" before
ZIP code and
remove "comma (,)
and telephone no,"
after ZIP code
Iincrease font size
("""-'

2525

·······.J ...\ f\..JIU

['J

,.

CORRECTED (if <:.J,e~ked)
1 Da:H option wanted

TR/\NSFEROR'S name, street address, city, state. ZIP cotierel\,Helepf'Of,e··I\o:.

2 Date option

TRANSF[ROR'S federal irJer1lifical!orl Ilumber

I

TR/\NSFEREE'S ,dentlfication nurnb8r

eXl~rcisQd

3 [x'vcise price per share

~

I
(Rev. December 2008)

I

~45-XXXX

Exercise of
A Qualified 1\;
",Incentive Stock ani
torm
Option Under
(Hev.,-Apfi1-2OO8l
Section ~ ...."., 422(b )1
.,r-{I.c. m/l.e, vlperll
4 Fair ,r,(arker 'Ialllfhif'M¥/£.
Copy B

share on exercise dJte
OMl!

392Q/

-

II';'.,')~
For Pelieyhel(jel'
Transferee/

TRANSFEREE'S name

$

$

5 No. 01 shares tranferred

6-¥-ea,...;p+io<\·-exereiseEI

!shade this box
Street address (incluclin(J apt. no.)

City, state, and ZIP code

l4.ccount number (see instructions)

/

-.I" "," '"'"

~m',

IRANse'RD"
" " " \ ElN .,
corporation whose
stock is being transferre

Ichange 7 to 6
Form

3921

(keep for your records)

Do NO;rut or Separate Forms on This Page
(Rev.

Deeember2008V

-

I

This is important tax
information and is being
I furnished to the Internal
Revenue Service. If you
are required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if this
item is required to be
reported and the IRS
determines that it has
not been reported.

Department of tile "·reasury - Internal Revenue SOrviCB

Do Not Cut or Separate

rms on This Page

remove 3rd "s" on
address, add
comma (,) after
"address"

Instructions for Transferee
A payer, such as your employer or a
stock transfer company who
transfers your employers stock to
you pursuant to the exercise of an
incentive stock option, must give this
form to you. You should retain this
form to help you report the proceeds
of sales of this stock until you have
made a complete disposition of the
stock. For assistance in reporting
dispositions of this stock, see Pub.
525, Taxable and Nontaxable
Income.
Account number. May show an
account or other unique number the
payer assigned to distinguish your
account.
Box 1. Shows the date the option to
purchase the stock was granted to
you.

Box 2. Shows the date you
exercised the option to purchase the
stock.
Box 3. Shows the exercise price per
share of stock.
Box 4. Shows the fair market value
(FMV) of a share of stock on the
date the option to purchase was
exercised.
Box 5. Shows the number of shares
transferred pursuant to the exercise
of the option.
Box 6. If other than the corporation
shown in TRANSFEROR boxes in
upper left corner on the front of this
page, shows the name, address, and
employer identification number (EIN)
of the corporation whose stock is
being transferred.

.­'7

Add "and" before
ZIP code and
remove "comma (,)
and telephone no."
after ZIP code
IIncrease font size
r'-"

.-2-£2-5

·__J ...\ TVll..I

[] CORRECTED (if checked)

TRANSFEROR'S name, streHt address, city, state, ZIP cOde{fmd-leieflPOf'le-·f\Oo'

1 Date option wanted

2 Date option exercised

TRANSFEROR'S federal irJ,lIllific31on number

I

I

~

OMB

(r~ev,

~~45-XXXX

Exercise of
A Qualified ~I
A,lncentive Stock ani
Option Under
Section ~ ~""L'422(b)1

~orm 392Q/
(ReFile Typeapplication/pdfFile Modified2008-09-04File Created2008-09-04