Form 3922 Transfer of Stock Acquired Through an Employee Stock Pur

2626

VOID

Version A, Cycle 2
Dimensions: 7.3" x 3.75"

CORRECTED

CORPORATION'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 3922
2 Date option exercised

(Rev. August 2013)
CORPORATION'S federal identification number EMPLOYEE’S identification number

3 Fair market value per share
on grant date

$

EMPLOYEE’S name

5 Exercise price paid per share

4 Fair market value per share
on exercise date

$
6 No. of shares transferred

$

City or town, province or state, country, and ZIP or foreign postal 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. 8-2013)

Cat. No. 41180P

www.irs.gov/form3922

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

7 Date legal title transferred

Street address (including apt. no.)

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

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

INTERNAL USE ONLY
DRAFT AS OF
April 17, 2013

Version A, Cycle 2
Dimensions: 7.3" x 3.75"

CORRECTED
CORPORATION'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 3922
2 Date option exercised

(Rev. August 2013)
CORPORATION'S federal identification number EMPLOYEE’S identification number

3 Fair market value per share
on grant date

$

EMPLOYEE’S name

5 Exercise price paid per share

4 Fair market value per share
on exercise date

$
6 No. of shares transferred

$
7 Date legal title transferred

Street address (including apt. no.)

Transfer of Stock
Acquired Through
an Employee
Stock Purchase
Plan Under
Section 423(c)
Copy B
For Employee
This is important tax
information and is
being furnished to
the Internal Revenue
Service.

City or town, province or state, country, and ZIP or foreign postal 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. 8-2013)

(keep for your records)

www.irs.gov/form3922

Department of the Treasury - Internal Revenue Service

INTERNAL USE ONLY
DRAFT AS OF
April 17, 2013

Version A, Cycle 2
Dimensions: 7.3" x 3.75"

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.
Future developments. For the latest information about
developments related to Form 3922 and its instructions, such
as legislation enacted after they were published, go to
www.irs.gov/form3922.

INTERNAL USE ONLY
DRAFT AS OF
April 17, 2013

VOID

Version A, Cycle 2
Dimensions: 7.3" x 3.75"

CORRECTED

CORPORATION'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 3922
2 Date option exercised

(Rev. August 2013)
CORPORATION'S federal identification number EMPLOYEE’S identification number
EMPLOYEE’S name

3 Fair market value per share
on grant date

$
5 Exercise price paid per share

4 Fair market value per share
on exercise date

$
6 No. of shares transferred

$
Street address (including apt. no.)

7 Date legal title transferred

City or town, province or state, country, and ZIP or foreign postal 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. 8-2013)

www.irs.gov/form3922

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
current version of the
General Instructions
for Certain
Information Returns.

Department of the Treasury - Internal Revenue Service

INTERNAL USE ONLY
DRAFT AS OF
April 17, 2013

Version A, Cycle 2
Dimensions: 7.3" x 3.75"

Instructions for Corporation
To complete Form 3922, 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/form3922 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). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).

INTERNAL USE ONLY
DRAFT AS OF
April 17, 2013