Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) (Page 2 of 7) in pdf

Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 2

VOID

CORRECTED

2525

TRANSFEROR'S name, street address, city or town, state or province, country, and

1 Date option granted

OMB No. 1545-2129

Exercise of an

ZIP or foreign postal code

Form 3921

Incentive Stock

Option Under

2 Date option exercised

Section 422(b)

(Rev. August 2013)

Copy A

TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

4 Fair market value per share

on exercise date

For

Internal Revenue

EMPLOYEE’S name

Service Center

5 No. of shares transferred

File with Form 1096.

For Privacy Act and

Street address (including apt. no.)

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

Paperwork

corporation whose stock is being transferred

Reduction Act

Notice, see the

City or town, state or province, country, and ZIP or foreign postal code

current version of

the General

Instructions for

Account number (see instructions)

Certain Information

Returns.

3921

Form

(Rev. August 2013)

Cat. No. 41179O

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

Form 3921 - Exercise Of An Incentive Stock Option Under Section 422(B) Page 2

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