Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) (Page 3 of 7) in pdf

Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 3

CORRECTED (if checked)

Exercise of an

TRANSFEROR’S name, street address, city, state, and ZIP code

Date option granted

OMB No. 1545-2129

Incentive Stock

Form 3921

Option Under

Section 422(b)

Date option exercised

(Rev. October 2010)

TRANSFEROR’S federal identification number

EMPLOYEE’S identification number

Exercise price per share

Fair market value per

Copy B

share on exercise date

For Employee

EMPLOYEE’S name

This is important tax

5 No. of shares transferred

information and is

being furnished to the

Internal Revenue

Service. If you are

Street address (including apt. no.)

If other than TRANSFEROR, name, address, and EIN of

required to file a return,

corporation whose stock is being transferred

a negligence penalty or

other sanction may be

City, state, and ZIP code

imposed on you if this

item is required to be

reported and the IRS

Account number (see instructions)

determines that it has

not been reported.

3921

(keep for your records)

Form

(Rev. October 2010)

Department of the Treasury - Internal Revenue Service

Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 3