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

Attention:
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printing these tax forms.

2525

VOID

CORRECTED

TRANSFEROR’S name, street address, city, state, and ZIP code

1 Date option granted

OMB No. 1545-2129

Form 3921
2 Date option exercised

TRANSFEROR’S federal identification number

EMPLOYEE’S name

EMPLOYEE’S identification number

(Rev. October 2010)

3 Exercise price per share

4 Fair market value per
share on exercise date

$

$

5 No. of shares transferred

Street address (including apt. no.)

6 If other than TRANSFEROR, name, address, and EIN of
corporation whose stock is being transferred

City, state, and ZIP code

Account number (see instructions)

Form

3921 (Rev. October 2010)

Cat. No. 41179O

Exercise of an
Incentive Stock
Option Under
Section 422(b)
Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act and
Paperwork
Reduction Act
Notice, see the most
current version of
the General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
TRANSFEROR’S name, street address, city, state, and ZIP code

1 Date option granted

OMB No. 1545-2129

Form 3921
2 Date option exercised

TRANSFEROR’S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

(Rev. October 2010)

4 Fair market value per
share on exercise date

Exercise of an
Incentive Stock
Option Under
Section 422(b)

Copy B
For Employee

EMPLOYEE’S name

$

$

5 No. of shares transferred

Street address (including apt. no.)

6 If other than TRANSFEROR, name, address, and EIN of
corporation whose stock is being transferred

City, state, and ZIP code

Account number (see instructions)

Form

3921 (Rev. October 2010)

(keep for your records)

This is important tax
information and is
being 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 the Treasury - Internal Revenue Service

Instructions for Employee
You have received this form because your employer (or
transfer agent) transferred your employer’s stock to
you pursuant to your exercise of an incentive stock
option (ISO). You must recognize (report) gain or loss
on your tax return for the year in which you sell or
otherwise dispose of the stock. Keep this form and use
it to figure the gain or loss. For more information, see
Pub. 525, Taxable and Nontaxable Income.
When you exercise an ISO, you may have to include
in alternative minimum taxable income a portion of the
fair market value of the stock acquired through the
exercise of the option. For more information, see Form
6251, Alternative Minimum Tax—Individuals, and its
instructions.
Account number. May show an account or other
unique number your employer or transfer agent
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 was exercised.
Box 5. Shows the number of shares of stock
transferred to you pursuant to the exercise of the
option.
Box 6. Shows the name, address, and employer
identification number (EIN) of the corporation whose
stock is being transferred (if other than the corporation
shown in TRANSFEROR boxes in the upper left corner
of the form).

CORRECTED (if checked)
TRANSFEROR’S name, street address, city, state, and ZIP code

1 Date option granted

OMB No. 1545-2129

Form 3921
2 Date option exercised

TRANSFEROR’S federal identification number

EMPLOYEE’S name

EMPLOYEE’S identification number

3 Exercise price per share

$

(Rev. October 2010)

4 Fair market value per
share on exercise date

$

Exercise of an
Incentive Stock
Option Under
Section 422(b)

Copy C
For Corporation

5 No. of shares transferred

Street address (including apt. no.)

6 If other than TRANSFEROR, name, address, and EIN of
corporation whose stock is being transferred

City, state, and ZIP code

This copy should
be retained by the
corporation whose
stock has been
transferred under
Section 422(b).

Account number (see instructions)

Form

3921 (Rev. October 2010)

(keep for your records)

Department of the Treasury - Internal Revenue Service

VOID

CORRECTED

TRANSFEROR’S name, street address, city, state, and ZIP code

1 Date option granted

OMB No. 1545-2129

Form 3921
2 Date option exercised

TRANSFEROR’S federal identification number

EMPLOYEE’S name

EMPLOYEE’S identification number

(Rev. October 2010)

3 Exercise price per share

4 Fair market value per
share on exercise date

$

$

5 No. of shares transferred

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form

3921 (Rev. October 2010)

6 If other than TRANSFEROR, name, address, and EIN of
corporation whose stock is being transferred

Exercise of an
Incentive Stock
Option Under
Section 422(b)

Copy D
For Transferor
For Privacy Act and
Paperwork
Reduction Act
Notice, see the
most current
version of the
General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Transferor
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 3921 are the most current General
Instructions for Certain Information Returns and the
most current Instructions for Forms 3921 and 3922. 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 IRS.gov or call 1-800-TAX-FORM
(1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file with the IRS Forms
1096, 1097, 1098, 1099, 3921, 3922, or 5498 that you
print from the IRS website.
Due dates. Furnish Copy B of this form to the
employee by January 31 of the year following the year
of exercise of the ISO.

Furnish Copy C of this form to the corporation
whose stock is being transferred by January 31 of the
year following the year of exercise of the ISO.
File Copy A of this form with the IRS by February 28
of the year following the year of exercise of the ISO. If
you file electroncially, the due date is March 31 of the
year following the year of exercise of the ISO. To file
electronically, you must have software that generates a
file according to the specifications in Pub. 1220,
Specifications for Filing Forms 1097, 1098, 1099, 3921,
3922, 5498, 8935, and W-2G Electronically. IRS does
not provide a fill-in form option.
Need help? If you have questions about reporting on
Form 3921, 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 304-579-4827 (not toll free). The hours of
operation are Monday through Friday from 8:30 a.m. to
4:30 p.m., Eastern time.