Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 3
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7CORRECTED (if checked)
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 B
TRANSFEROR’S TIN
EMPLOYEE’S TIN
3 Exercise price per share
4 Fair market value per share
on exercise date
For Employee
$
$
EMPLOYEE’S name
This is important tax
information and is
5 No. of shares transferred
being furnished to the
IRS. If you are required
to file a return, a
Street address (including apt. no.)
6 If other than TRANSFEROR, name, address, and TIN of
negligence penalty or
corporation whose stock is being transferred
other sanction may be
imposed on you if this
City or town, state or province, country, and ZIP or foreign postal code
item is required to be
reported and the IRS
determines that it has
Account number (see instructions)
not been reported.
3921
(keep for your records)
Form
(Rev. October 2017)
Department of the Treasury - Internal Revenue Service
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