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

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VOID
CORRECTED
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 D
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 EIN of
Notice, see the
corporation whose stock is being transferred
most current
version of the
City, state, and ZIP code
General
Instructions for
Certain Information
Account number (see instructions)
Returns.
3921
Form
(Rev. October 2010)
Department of the Treasury - Internal Revenue Service

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