WRN for Form 3921

Tax Forms & Publications

Work Request Notification
Title: Form 3921 Exercise of an Incentive Stock Option Under Section 422(b)
Tax Year: 2009

Processing Year: 2010

Route to:

Approved:

Section Chief:
Reviewer:
Review Chief:
Branch Chief:

Ellen Fingerman

Date:

Ellen
Fingerman

S80BB

Mark Richter
Karl Blake (acting)
N/A

Karl Blake

Digitally signed by 62PDB
DN: cn=62PDB, [email protected]
Date: 2008.08.14 12:45:02 -04'00'

08/13/08

Digitally signed by S80BB
DN: cn=S80BB, [email protected]
Date: 2008.08.15 08:35:47 -04'00'

08/15/08

KC9BB
cn=KC9BB, [email protected]
I am approving this document
SE:W:CAR:MP:T:I:R
2008.08.15 09:36:31 -04'00'

08/15/08

Digitally signed by B50DB
DN: cn=B50DB, [email protected]
Date: 2008.08.19 18:30:52 -04'00'

Senior Technical Advisor: Bob Erickson
Initiator (Tax Law Specialist): Melody

DeVoe

GH1LB

Digitally signed by GH1LB
DN: cn=GH1LB, email=Melody.G.Devoe@irs.
gov
Date: 2008.08.20 09:48:41 -04'00'

08/20/08

The information in this document can be used to develop any necessary Work Requests.
This notification is for changes due to:
✔ Legislation or Chief Counsel guidance:

A Program change initiated by:
The major changes are as follows:
This is a major revision of a form last used in 1978. The revision is made to reflect proposed regulations 1.6039-1(a), to be made
final by October 2008, which require corporations that transfer stock pursuant to an employee's exercise of an incentive stock
option described in section 422(b) to file Form 3921 for each transfer. Form 3921 is required to be filed for transfers occurring
after 2008.
Information is to be reported as follows:
1. The name, address, and employer identification number of the corporation transferring the stock.
2. The name, address, and identifying number of the person to whom the share(s) of stock were transferred pursuant to the
exercise of the option.
3. The date the option was granted to the person (Box 1).
4. The date the option was exercised by the person (Box 2).
5. The exercise price per share (Box 3).
6. The fair market value of a share of stock on the date the option was exercised by the person (Box 4).
7. The number of shares transferred to the person pursuant to the exercise of the option (Box 5).
8. If other than the corporation identified in (1), the name, address, and employer identification number of the corporation whose
stock is being transferred (Box 6).

✔ We may need to make further changes that would require a work request.

We do not anticipate the need for any further changes that would require a Work Request.
If you have any questions, please contact:
Name: Melody G. DeVoe

Name: Mark Richter

Title:

Title:

Tax Law Specialist

Tax Law Specialist (Reviewer)

Symbols: SE:W:CAR:MP:T:I:P

Symbols: SE:W:CAR:MP:T:I:R

Phone: 202-283-7635

Phone: 202-622-3105

Email: [email protected]

Email: [email protected]

Room: C7-143 NCFB

Room: 6429 Main IR

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2525

(Rev. December 2008)

VOID

CORRECTED

TRANSFEROR’S name, street address, city, state, ZIP code, and telephone no.

1 Date option granted

OMB No. 1545-XXXX

Form 3921

TRANSFEROR’S federal identification number

TRANSFEREE’S identification number

TRANSFEREE’S name

2 Date option exercised

(Rev. April 2008)

3 Exercise price per share

4 Fair Market Value (FMV) /
share on exercise date

$

$

5 No. of shares tranferred

6 Year option exercised

shade this box

Exercise of
A Qualified
Incentive Stock an/
Option Under
Section 442(b) 422(b)/
Copy A
For
Internal Revenue
Service Center
File with Form 1096.

Street address (including apt. no.)
7 If other than TRANSFEROR, name, addresss and EIN of
corporation whose stock is being transferred

City, state, and ZIP code

l.c. m/l.c. v/per/

Account number (see instructions)

change 7 to 6
Form

3921

Cat. No. 41179O

Do Not Cut or Separate Forms on This Page
(Rev. December 2008)/

—

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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address, add
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"address"