Form 3921 - Exercise Of An Incentive Stock Option Under Section 422b

CORRECTED (if checked)

TRANSFEROR'S name, street address, city or town, state or province, country, and

1 Date option granted

OMB No. 1545-2129

ZIP or foreign postal code

Exercise of an

Form 3921

Incentive Stock

Option Under

2 Date option exercised

Section 422(b)

(Rev. August 2013)

Copy B

TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

4 Fair market value per share

on exercise date

For Employee

This is important tax

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

information and is

5 No. of shares transferred

being furnished to the

Internal Revenue

Service. If you are

6 If other than TRANSFEROR, name, address, and EIN of

required to file a return,

corporation whose stock is being transferred

a negligence penalty or

other sanction may be

imposed on you if this

item is required to be

reported and the IRS

Account number (see instructions)

determines that it has

not been reported.

3921

(keep for your records)

Department of the Treasury - Internal Revenue Service

Form

(Rev. August 2013)

CORRECTED (if checked)

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 B

TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

4 Fair market value per share

on exercise date

For Employee

This is important tax

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

information and is

5 No. of shares transferred

being furnished to the

Internal Revenue

Service. If you are

6 If other than TRANSFEROR, name, address, and EIN of

required to file a return,

corporation whose stock is being transferred

a negligence penalty or

other sanction may be

imposed on you if this

item is required to be

reported and the IRS

Account number (see instructions)

determines that it has

not been reported.

3921

(keep for your records)

Department of the Treasury - Internal Revenue Service

Form

(Rev. August 2013)

CORRECTED (if checked)

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 B

3 Exercise price per share

4 Fair market value per share

TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

on exercise date

For Employee

This is important tax

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

information and is

5 No. of shares transferred

being furnished to the

Internal Revenue

Service. If you are

6 If other than TRANSFEROR, name, address, and EIN of

required to file a return,

corporation whose stock is being transferred

a negligence penalty or

other sanction may be

imposed on you if this

item is required to be

reported and the IRS

Account number (see instructions)

determines that it has

not been reported.

3921

(keep for your records)

Department of the Treasury - Internal Revenue Service

Form

(Rev. August 2013)

3921B

Form 3921 - Exercise Of An Incentive Stock Option Under Section 422b - Black

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