Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 6

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VOID
CORRECTED
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 D
TRANSFEROR’S TIN
EMPLOYEE’S TIN
3 Exercise price per share
4 Fair market value per share
on exercise date
For Transferor
$
$
EMPLOYEE’S name
For Privacy Act and
5 No. of shares transferred
Paperwork
Reduction Act
Street address (including apt. no.)
6 If other than TRANSFEROR, name, address, and TIN of
Notice, see the
corporation whose stock is being transferred
current version of
the General
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
Certain Information
Returns.
Account number (see instructions)
3921
Form
(Rev. October 2017)
Department of the Treasury - Internal Revenue Service

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