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TRANSFEROR’S name, street address, city or town, state or province, |
1 Date option granted |
OMB No. 1545-2129 |
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Exercise of an |
country, and ZIP or foreign postal code |
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Form 3921 |
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Incentive Stock |
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Option Under |
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2 Date option exercised |
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(Rev. October 2017) |
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Section 422(b) |
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TRANSFEROR’S TIN |
EMPLOYEE’S TIN |
3 Exercise price per share |
4 Fair market value per share |
Copy A |
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on exercise date |
For |
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EMPLOYEE’S name |
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$ |
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Internal Revenue |
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Service Center |
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5 No. of shares transferred |
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File with Form 1096. |
Street address (including apt. no.) |
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6 If other than TRANSFEROR, name, address, and TIN of |
For Privacy Act and |
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Paperwork |
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corporation whose stock is being transferred |
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Reduction Act |
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City or town, state or province, country, and ZIP or foreign postal code |
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Notice, see the |
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current version of |
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the General |
Account number (see instructions) |
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Instructions for |
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Certain Information |
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Returns. |
Form 3921 (Rev. October 2017) |
Cat. No. 41179O |
www.irs.gov/Form3921 |
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