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)

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 B

TRANSFEROR'S federal identification number

EMPLOYEE’S identification number

3 Exercise price per share

4 Fair market value per share

on exercise date

For Employee

This is important tax

EMPLOYEE’S name

information and is

5 No. of shares transferred

being furnished to the

Internal Revenue

Service. If you are

Street address (including apt. no.)

6 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 or town, state or province, country, and ZIP or foreign postal 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. August 2013)

Department of the Treasury - Internal Revenue Service

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

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