Form 3922 Transfer of Stock Acquired Through an Employee Stock Pur

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ZIP code and

remove "comma (,)

and telephone no."

after ZIP code

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(Rev. December 2008)

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[] CORRECTED

CORf'ORATION'S name, street address, City, state, ZIP code/8fld..t~O/le+ie,

Transfer of Stock
Acquired Through
..An Employee I.e.!
Stock Purchase
Plan Under
Section 423(c)

1 Date option granted to
TRANSFEROR

2 Date option exerciscJd
by TRANSFEROR

CORPORATION'S federal 'derilifcation lIumber TRANSFEROR'S identification number

3 Fair markel valut' per share

on want date

$

$

TRANSFEROR'S name

5 E.xercisE.! price per
"'s-'t-Je-e-t,-ad-d-re-,s-s-(in-c-lu-d-in-rJ-a-pt-.-no-.•- I- - - - - - - - - - - - - 1

City, state, amf ZIP code

Account number (see instructions)

$.

4 Fair rnarkel vaiui] per share on
exercisE1 date

ShiFC

6 NQ.

[)f

shares transferred

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099, 1098,
5498, and W-2G.

Cat.

ut or Separate Forms on This Page

Insert: 3921, 3922,/

III

Add "and" before

ZIP code and

remove "comma (,)
and telephone no."
after ZI P code

Increase font size
(Rev, December 2008)

[] CORRECTED

Transfer of Stock
Acquired Through
.An Employee I.e.!
Stock Purchase
Plan Under
Section 423(c)

1 Date option qranted to
TRANSFEROR

2 Dat" option exercised
by TRANSFEROR

CORPORATION'S felleral iden{WC;1ron number TRANSFEROR'S identification number

3 Fair mdrket ".1,," per stlare

4 Fair markel

on grant da!e

TRANSFEROR'S name

$

VaiLI(;

City, state, and ZIP code

Account number (see instructions)

ut or Separate Forms on This Page

(Ill

Copy B
For Policyholder

$

This is important tax
and is being
furnished to the Internal
Revenue Service,~y

i5-Exercise
-=- - - - - - - - t - " - - - - - - - - - j information
prjce per sh~re
6 No, of shares

Street address (inciudin(J apt. no,i

per share

exercise date

transrl~rred

r urn, a negligence
enalty or other
s ction may be
imposed
ou if this
item is requi d to be
IRS
reported and t
determines that it as

-'1/
1

Instructions for Transferor
This information statement is being
furnished to you with respect to the
transfer or transfers of stock
acquired through an employee stock
purchase plan. You should retain
this information return until you have
satisfied your tax obligations upon
disposition of the shares. See Pub.
525, Taxable and Nontaxable
Income, for assistance in reporting
dispositions of this stock. The
information in boxes 1-5 will enable
you to determine your tax
obligation(s) upon the disposition of
shares.
Account number. May show an
account or other unique number the
payer assigned to distinguish your
account.
Box 1. Show 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 fair market value
(FMV) per share on the option grant
date.
Box 4. Shows the FMV per share on
the option exercise date.
Box 5. Shows the price per share
on the date the option was
exercised.
Box 6. Shows the number of shares
to which legal title was transferred by
you.
Box 7. Shows the date legal title of
the shares was transferred by you.

ot-

Add "and" before

ZIP code and

remove "comma (,)

and telephone no."

after ZI P code

Increase font size
(Rev. December 2008)

10

[::J CORRECTED

CORF'ORATION'S name. street addmss. City, state, ZIP codel f.lt,d-~elef.>ftooo·j,e-.. 1 Datfl option granted to
TRANSFEROR

2 Date option exercised
by TRANSFEROR

CORPORATION'S federal idenlificat:!Jn number TRANSFEROR'S identification number

TRANSFEROR'S name

Street address (includinfJ apt. no.)

City, state. and ZIP code

Account number (see instructions)

ut or Separate Forms on This Page

3 Fall' markel value per sharB
on want date

$

Transfer of Stock
Acquired Through
.An Employee I.e.!
Stock Purchase

Plan Under

Section 423(c)

4 Falr market varue per share on
exercise date

$
f-=---------I--=---------1
5 Exercise price per share
6 No. of shares transrerred

Copy C
For Corporation
This copy should
be retained by the
corporation.

POJC:
3

Page 9- ef 6 of Fotm-·199S

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Insert: 3921, 3922,/

Instructions for Resipients/L9Rd9rs

F; ler ..

General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1098 are the 2009 General Instructions
for Forms 1099, 1098, 5498, and W-2G and the 2009
Instructions for Form 1098. A chart in the general
instructions gives a quick guide to which form must be
filed to report a particular payment. To order these
instructions and additional forms, visit the IRS website
at www.irs.gov or call 1-800-TAX-FORM
(1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1098, 1099,
or 5498 that you print from the IRS website.

File Copy A of this form with the IRS by
March 1, 2010. If you file electronically, the due date
is March 31, 2010. To file electronically, you must
have software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1098, 1099, 5498, and W-2G Electronically.
IRS does not provide a fill-in form option.
Need help? If you have questions about reporting on
Form 1098, call the information reporting customer
service site toll free at 1-866-455-7438 or
304-263-8700 (not toll free). For TTY!TDD equipment,
call 304-267-3367 (not toll free).

Due dates. Furnish Copy B of this form to the payer
by February 1, 2010.

*

Printed on recycled paper