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Form 3922 - Transfer Of Stock Acquired Through An Employee Stock Purchase Plan Under Section 423(C) Page 5

VOID

CORRECTED

Transfer of Stock

CORPORATION'S name, street address, city or town, state or province,

1 Date option granted

OMB No. 1545-2129

country, and ZIP or foreign postal code

Acquired Through

Form 3922

an Employee

Stock Purchase

2 Date option exercised

Plan Under

(Rev. August 2013)

Section 423(c)

Copy C

CORPORATION'S federal identification number EMPLOYEE’S identification number

3 Fair market value per share

4 Fair market value per share

on grant date

on exercise date

For Corporation

EMPLOYEE’S name

This copy should be

retained by the

5 Exercise price paid per share

6 No. of shares transferred

corporation.

Street address (including apt. no.)

7 Date legal title transferred

For Privacy Act and

Paperwork Reduction

Act Notice, see the

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

current version of the

8 Exercise price per share determined as if the option was

General Instructions

exercised on the date shown in box 1.

for Certain

Account number (see instructions)

Information Returns.

3922

Form

(Rev. 8-2013)

Department of the Treasury - Internal Revenue Service

Form 3922 - Transfer Of Stock Acquired Through An Employee Stock Purchase Plan Under Section 423(C) Page 5

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