Instructions For Forms 3921 And 3922 (Rev. August 2013) Page 2
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2Statements to Transferors
Specific Instructions for Form 3922
If you are required to file Form 3922, you must furnish a
statement to the transferor. For more information, see part
Who Must File
M in the current version of the General Instructions for
Every corporation, which in any calendar year records, or
Certain Information Returns.
has by its agent recorded, a transfer of the legal title of a
Employee's Name, Address, and Identification
share of stock acquired by the transferor (person who
acquires the shares pursuant to the exercise of the option)
Number
pursuant to the transferor's exercise of an option granted
Enter the name, address, and identifying number of the
under an employee stock purchase plan and described in
transferor.
section 423(c) (where the exercise price is less than
100% of the value of the stock on the date of grant, or is
Account Number
not fixed or determinable on the date of grant), must, for
The account number is required if you have multiple
that calendar year, file Form 3922 for each transfer made
accounts for a transferor for whom you are filing more
during that year.
than one Form 3922. Additionally, the IRS encourages
A return is required by reason of a transfer described in
you to designate an account number for all Forms 3922
section 6039(a)(2) only for the first transfer of legal title of
that you file. See part L in the current version of the
the shares by the transferor, including the first transfer of
General Instructions for Certain Information Returns.
legal title to a recognized broker or financial institution. If a
Box 1. Date Option Granted
contractual agreement exists or is entered into with a
recognized broker or financial institution pursuant to which
Enter the date the option was granted.
shares acquired upon exercise of the option will be
Box 2. Date Option Exercised
immediately deposited into a brokerage account
established on behalf of the transferor, then the deposit of
Enter the date the option was exercised.
shares by the transferor into the brokerage account
following the exercise of the option is the first transfer of
Box 3. Fair Market Value Per Share on Grant
legal title of the shares acquired by the transferor, and the
Date
corporation is only required to file a return relating to that
Enter the fair market value (FMV) per share of stock on
transfer of legal title.
the date the option was granted.
Shares of stock transferred as a result of the exercise
Box 4. Fair Market Value Per Share on Exercise
of an option described above must be identified in a
manner sufficient to enable the accurate reporting of the
Date
transfer of legal title to such shares. This identification can
Enter the FMV per share of stock on the date the option to
be made by assigning to the share certificates of stock
purchase the stock was exercised.
issued pursuant to such options a special serial number or
color.
Box 5. Exercise Price Paid Per Share
The corporation whose stock is being transferred must
Enter the price paid per share on the date the option was
file Form 3922.
exercised.
Exception. A Form 3922 is not required for the first
Box 6. Number of Shares Transferred
transfer of legal title of a share of stock by an employee
Enter the number of shares to which legal title was
who is a nonresident alien (as defined in section 7701(b))
transferred.
and to whom the corporation is not required to provide a
Form W-2, Wage and Tax Statement, for any calendar
Box 7. Date Legal Title Transferred
year within the time period beginning with the first day of
Enter the date legal title of the shares was first transferred.
the calendar year in which the option was granted to the
employee and ending on the last day of the calendar year
Box 8. Exercise Price Per Share Determined as
in which the employee first transferred legal title to shares
if the Option Was Exercised on the Date Shown
acquired under the option. For this purpose, the term
in Box 1
“corporation” is defined in section 7701(a) and includes,
but is not limited to:
If the exercise price per share was not fixed or
The corporation issuing the stock,
determinable on the date of grant entered in box 1, enter
A related corporation of the corporation,
the exercise price per share determined as if the option
Any agent of the corporation,
was exercised on the date of grant entered in box 1. If the
Any party distributing shares of stock or other payments
exercise price per share is fixed or determinable on the
in connection with the plan (for example, a brokerage
date of grant entered in box 1, then leave box 8 blank.
firm), and
Any party in control of the payment of remuneration for
employment to the employee.
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Instrs for Forms 3921 and 3922 (Rev. Aug. 2013)
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