Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 2
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7VOID
CORRECTED
2525
TRANSFEROR’S name, street address, city or town, state or province,
1 Date option granted
OMB No. 1545-2129
Exercise of an
country, and ZIP or foreign postal code
Form 3921
Incentive Stock
Option Under
2 Date option exercised
Section 422(b)
(Rev. October 2017)
Copy A
TRANSFEROR’S TIN
EMPLOYEE’S TIN
3 Exercise price per share
4 Fair market value per share
on exercise date
For
Internal Revenue
$
$
EMPLOYEE’S name
Service Center
5 No. of shares transferred
File with Form 1096.
For Privacy Act and
Street address (including apt. no.)
6 If other than TRANSFEROR, name, address, and TIN of
Paperwork
corporation whose stock is being transferred
Reduction Act
Notice, see the
City or town, state or province, country, and ZIP or foreign postal code
current version of
the General
Instructions for
Account number (see instructions)
Certain Information
Returns.
3921
Form
(Rev. October 2017)
Cat. No. 41179O
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
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