Form 3922 Transfer of Stock Acquired Through an Employee Stock Pur

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar to the
official IRS form. Do not file copy A downloaded from this website with the SSA. The official
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distribution to your employees, and for your records.
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printing these tax forms.

2626

VOID

CORRECTED

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

1 Date option granted

OMB No. 1545-2129

Form 3922
2 Date option exercised

(Rev. October 2010)
CORPORATION’S federal identification number

EMPLOYEE’S identification number

3 Fair market value per share 4 Fair market value per share
on grant date
on exercise date

$

EMPLOYEE’S name

$

5 Exercise price paid per share 6 No. of shares transferred

$
Street address (including apt. no.)

7 Date legal title transferred

City, state, and ZIP code
8 Exercise price per share determined as if the option was
exercised on the date shown in box 1.

Account number (see instructions)

$
Form

3922 (Rev. October 2010)

Cat. No. 41180P

Do Not Cut or Separate Forms on This Page

Transfer of Stock
Acquired Through
an Employee
Stock Purchase
Plan Under
Section 423(c)

—

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

CORRECTED
CORPORATION’S name, street address, city, state, and ZIP code

1 Date option granted

OMB No. 1545-2129

Form 3922
2 Date option exercised

(Rev. October 2010)
CORPORATION’S federal identification number

EMPLOYEE’S name

EMPLOYEE’S identification number

3 Fair market value per share 4 Fair market value per share
on grant date
on exercise date

$

$

5 Exercise price paid per share 6 No. of shares transferred

$
Street address (including apt. no.)

Transfer of Stock
Acquired Through
an Employee
Stock Purchase
Plan Under
Section 423(c)

7 Date legal title transferred

Copy B
For Employee
This is important tax
information and is
being furnished to
the Internal Revenue
Service.

City, state, and ZIP code

Account number (see instructions)

8 Exercise price per share determined as if the option was
exercised on the date shown in box 1.

$
Form

3922 (Rev. October 2010)

(keep for your records)

Department of the Treasury - Internal Revenue Service

Instructions for Employee
You have received this form because (1) your employer
(or its transfer agent) has recorded a first transfer of
legal title of stock you acquired pursuant to your
exercise of an option granted under an employee stock
purchase plan and (2) the exercise price was less than
100 percent of the value of the stock on the date
shown in box 1 or was not fixed or determinable on
that date.
No income is recognized when you exercise an
option under an employee stock purchase plan.
However, 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.
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 fair market value (FMV) per share on
the date the option to purchase the stock was granted
to you.
Box 4. Shows the FMV per share on the date you
exercised the option to purchase the stock.
Box 5. Shows the price paid per share on the date you
exercised the option to purchase the stock.
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
first transferred by you.
Box 8. If the exercise price per share was not fixed or
determinable on the date entered in box 1, box 8
shows the exercise price per share determined as if
the option was exercised on the date in box 1. If the
exercise price per share was fixed or determinable on
the date shown in box 1, then box 8 will be blank.

VOID

CORRECTED

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

1 Date option granted

OMB No. 1545-2129

Form 3922
2 Date option exercised

(Rev. October 2010)
CORPORATION’S federal identification number

EMPLOYEE’S name

EMPLOYEE’S identification number

3 Fair market value per share 4 Fair market value per share
on grant date
on exercise date

$

$

5 Exercise price paid per share 6 No. of shares transferred

$
Street address (including apt. no.)

7 Date legal title transferred

City, state, and ZIP code

Account number (see instructions)

8 Exercise price per share determined as if the option was
exercised on the date shown in box 1.

$
Form

3922 (Rev. October 2010)

Transfer of Stock
Acquired Through
an Employee
Stock Purchase
Plan Under
Section 423(c)
Copy C
For Corporation
This copy should
be retained by the
corporation.
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 Corporation
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 3922 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 first transfer of the stock acquired through the
employee stock purchase plan.

File Copy A of this form with the IRS by February 28
of the year following the year of first transfer of the
stock acquired through the employee stock purchase
plan. If you file electronically, the due date is March 31
of the year following the year of first transfer of the
stock acquired through the employee stock purchase
plan. 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 3922, 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.