Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 5

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CORRECTED (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)
TRANSFEROR’S TIN
EMPLOYEE’S TIN
3 Exercise price per share
4 Fair market value per share
on exercise date
Copy C
$
$
For Corporation
EMPLOYEE’S name
5 No. of shares transferred
This copy should
be retained by the
Street address (including apt. no.)
6 If other than TRANSFEROR, name, address, and TIN of
corporation whose
corporation whose stock is being transferred
stock has been
transferred under
City or town, state or province, country, and ZIP or foreign postal code
Section 422(b).
Account number (see instructions)
3921
(keep for your records)
Form
(Rev. October 2017)
Department of the Treasury - Internal Revenue Service

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