Form 3922 - Transfer Of Stock Acquired Through An Employee Stock Purchase Plan Under Section 423(C)

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VOID
CORRECTED
2626
Transfer of Stock
CORPORATION'S name, street address, city or town, state or province,
1 Date option granted
OMB No. 1545-2129
country, and ZIP or foreign postal code
Acquired Through
Form 3922
an Employee
Stock Purchase
2 Date option exercised
Plan Under
(Rev. September 2016)
Section 423(c)
Copy A
CORPORATION'S federal identification number EMPLOYEE’S identification number
3 Fair market value per share
4 Fair market value per share
on grant date
on exercise date
For
Internal Revenue
$
$
EMPLOYEE’S name
Service Center
5 Exercise price paid per share
6 No. of shares transferred
$
File with Form 1096.
Street address (including apt. no.)
7 Date legal title transferred
For Privacy Act and
Paperwork Reduction
Act Notice, see the
City or town, state or province, country, and ZIP or foreign postal code
current version of the
8 Exercise price per share determined as if the option was
General Instructions for
exercised on the date shown in box 1
Certain Information
Account number (see instructions)
Returns.
$
3922
Form
(Rev. 9-2016)
Cat. No. 41180P
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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