burden

Burden Computation - Special Business Forms
Page 1 of 1

November 7, 2011

Product:
Description:
Variables
Responses.......
Line Items......
Forms Prepared..

3921/
Exercise of an Incentive Stock Option Under Section 422(b)
2010

Changes (+ -)

50,000
______________
11
______________
0.85
______________

_____________________________
_____________________________
_____________________________

2011
50,000
______________
11
______________
0.85
______________

Computation of Changes
50,000 x _____________
0.17
Old Computation (Prog. Change) ______________
50,000 x _____________
0.17
New Computation.............. ______________
Balance...

=
=

8,500
_______________
8,500
_______________
0
_______________

Old Computation (Adjustment)
New Computation..............
Balance...

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

Old Computation..............
New Computation..............
Balance...

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

Summary
Old Burden...................................................
Program Change...............................................
Adjustment...................................................
New Burden...................................................

8,500
_______________
0
_______________
_______________
8,500
_______________

Paperwork Reduction Act Notice
Time Per Response
0.17
Record Keeping............
Learning..................
Preparing.................
Sending...................

Notes:
No change.

Average Hours
Per Response
______________
______________
0.17
______________
______________

Average Time
Per Response
___________________
___________________
0 hrs. , 10 min.
___________________
___________________