Form 3921 Exercise Of An Incentive Stock Option Under Section 422
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1VOID
CORRECTED
1 Date option granted
OMB No. 1545-2129
TRANSFEROR'S name, street address, city or town, state or province, country, and
Exercise of an
ZIP or foreign postal code
Form 3921
Incentive Stock
Option Under
2 Date option exercised
Section 422(b)
(Rev. August 2013)
Copy D
TRANSFEROR'S federal identification number
EMPLOYEE’S identification number
3 Exercise price per share
4 Fair market value per share
on exercise date
For Transferor
$
$
RECIPIENT'S name, street address, city or town, province or state, country, and ZIP or foreign postal code
For Privacy Act and
5 No. of shares transferred
Paperwork
Reduction Act
6 If other than TRANSFEROR, name, address, and EIN of
Notice, see the
corporation whose stock is being transferred
current version of
the General
Instructions for
Certain Information
Returns.
Account number (see instructions)
3921
Department of the Treasury - Internal Revenue Service
Form
(Rev. August 2013)
VOID
CORRECTED
OMB No. 1545-2129
TRANSFEROR'S name, street address, city or town, state or province, country, and
1 Date option granted
Exercise of an
ZIP or foreign postal code
Form 3921
Incentive Stock
Option Under
2 Date option exercised
Section 422(b)
(Rev. August 2013)
Copy D
TRANSFEROR'S federal identification number
EMPLOYEE’S identification number
3 Exercise price per share
4 Fair market value per share
on exercise date
For Transferor
$
$
RECIPIENT'S name, street address, city or town, province or state, country, and ZIP or foreign postal code
For Privacy Act and
5 No. of shares transferred
Paperwork
Reduction Act
6 If other than TRANSFEROR, name, address, and EIN of
Notice, see the
corporation whose stock is being transferred
current version of
the General
Instructions for
Certain Information
Returns.
Account number (see instructions)
3921
Department of the Treasury - Internal Revenue Service
Form
(Rev. August 2013)
VOID
CORRECTED
TRANSFEROR'S name, street address, city or town, state or province, country, and
1 Date option granted
OMB No. 1545-2129
Exercise of an
ZIP or foreign postal code
Form 3921
Incentive Stock
Option Under
2 Date option exercised
Section 422(b)
(Rev. August 2013)
Copy D
3 Exercise price per share
4 Fair market value per share
TRANSFEROR'S federal identification number
EMPLOYEE’S identification number
on exercise date
For Transferor
$
$
RECIPIENT'S name, street address, city or town, province or state, country, and ZIP or foreign postal code
For Privacy Act and
5 No. of shares transferred
Paperwork
Reduction Act
6 If other than TRANSFEROR, name, address, and EIN of
Notice, see the
corporation whose stock is being transferred
current version of
the General
Instructions for
Certain Information
Returns.
Account number (see instructions)
3921
Department of the Treasury - Internal Revenue Service
Form
(Rev. August 2013)
3921D
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