Form 3921 Excise of an Incentive Stock Option Under Section 422(b)

Version A, Cycle 2

2525

VOID

CORRECTED

TRANSFEROR'S name, street address, city or town, province or state, country,
and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. August 2013)
TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

$

EMPLOYEE’S name

4 Fair market value per share
on exercise date

$

5 No. of shares transferred
6 If other than TRANSFEROR, name, address, and EIN of
corporation whose stock is being transferred

Street address (including apt. no.)
City or town, province or state, country, and ZIP or foreign postal code
Account number (see instructions)
Form 3921 (Rev. August 2013)

Cat. No. 41179O

www.irs.gov/form3921

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
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

Version A, Cycle 2

CORRECTED (if checked)
TRANSFEROR'S name, street address, city or town, province or state, country,
and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. August 2013)
TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

$

EMPLOYEE’S name

4 Fair market value per share
on exercise date

$

5 No. of shares transferred
6 If other than TRANSFEROR, name, address, and EIN of
corporation whose stock is being transferred

Street address (including apt. no.)
City or town, province or state, country, and ZIP or foreign postal code
Account number (see instructions)
Form 3921 (Rev. August 2013)

(keep for your records)

www.irs.gov/form3921

Exercise of an
Incentive Stock
Option Under
Section 422(b)
Copy B
For Employee
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

Version A, Cycle 2

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).
Future developments. For the latest information about
developments related to Form 3921 and its instructions,
such as legislation enacted after they were published,
go to www.irs.gov/form3921.

Version A, Cycle 2

CORRECTED (if checked)
TRANSFEROR'S name, street address, city or town, province or state, country,
and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. August 2013)
TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

$

EMPLOYEE’S name

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

Street address (including apt. no.)
City or town, province or state, and ZIP or foreign postal 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. August 2013)

(keep for your records)

www.irs.gov/form3921

Department of the Treasury - Internal Revenue Service

Version A, Cycle 2

VOID

CORRECTED

TRANSFEROR'S name, street address, city or town, province or state, country
and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. August 2013)
TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

$

EMPLOYEE’S name

4 Fair market value per share
on exercise date

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

City or town, province or state, country and ZIP or foreign postal code
Account number (see instructions)
Form 3921 (Rev. August 2013)

www.irs.gov/form3921

Copy D
For Transferor

$

5 No. of shares transferred
Street address (including apt. no.)

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

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

Department of the Treasury - Internal Revenue Service

Version A, Cycle 2

Instructions for Transferor
To complete Form 3921, use:
• The most current General Instructions for Certain
Information Returns, and
• The most current Instructions for Forms 3921 and
3922.
To order these instructions and additional forms, go
to www.irs.gov/forms3921 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 electronically, 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). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).