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

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CORRECTED (if checked)
Exercise of an
TRANSFEROR’S name, street address, city, state, and ZIP code
1
Date option granted
OMB No. 1545-2129
Incentive Stock
Form 3921
Option Under
Section 422(b)
2
Date option exercised
(Rev. October 2010)
TRANSFEROR’S federal identification number
EMPLOYEE’S identification number
3
Exercise price per share
4
Fair market value per
Copy C
share on exercise date
$
$
EMPLOYEE’S name
For Corporation
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 EIN of
corporation whose
corporation whose stock is being transferred
stock has been
transferred under
City, state, and ZIP code
Section 422(b).
Account number (see instructions)
3921
(keep for your records)
Form
(Rev. October 2010)
Department of the Treasury - Internal Revenue Service

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