3921 Excise of an Incentive Stock Option Under Section 422(b)

Attention:
Copy A of this form is provided for informational purposes only. Copy A appears in red,
similar to the official IRS form. The official printed version of Copy A of this IRS form is
scannable, but the online version of it, printed from this website, is not. Do not print and file
copy A downloaded from this website; a penalty may be imposed for filing with the IRS
information return forms that can’t be scanned. See part O in the current General
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more
information about penalties.
Please note that Copy B and other copies of this form, which appear in black, may be
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the recipient.
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forms.

2525

VOID

CORRECTED

TRANSFEROR’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. October 2017)
TRANSFEROR’S TIN

EMPLOYEE’S TIN

3 Exercise price per share

$

EMPLOYEE’S name

4 Fair market value per share
on exercise date

$

5 No. of shares transferred
6 If other than TRANSFEROR, name, address, and TIN of
corporation whose stock is being transferred

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 3921 (Rev. October 2017)

Cat. No. 41179O

www.irs.gov/Form3921

Exercise of an
Incentive Stock
Option Under
Section 422(b)
Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act and
Paperwork
Reduction Act
Notice, see the
current version of
the General
Instructions for
Certain Information
Returns.

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

CORRECTED (if checked)
TRANSFEROR’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. October 2017)
TRANSFEROR’S TIN

EMPLOYEE’S TIN

3 Exercise price per share

$

EMPLOYEE’S name

4 Fair market value per share
on exercise date

$

5 No. of shares transferred
6 If other than TRANSFEROR, name, address, and TIN of
corporation whose stock is being transferred

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 3921 (Rev. October 2017)

(keep for your records)

www.irs.gov/Form3921

Exercise of an
Incentive Stock
Option Under
Section 422(b)
Copy B
For Employee
This is important tax
information and is
being furnished to the
IRS. If you are required
to file a return, a
negligence penalty or
other sanction may be
imposed on you if this
item is required to be
reported and the IRS
determines that it has
not been reported.

Department of the Treasury - Internal Revenue Service

Instructions for Employee
You have received this form because your employer (or transfer
agent) transferred your employer’s stock to you pursuant to your
exercise of an incentive stock option (ISO). You must recognize
(report) gain or loss on your tax return for the year in which you
sell or otherwise dispose of the stock. Keep this form and use it to
figure the gain or loss. For more information, see Pub. 525,
Taxable and Nontaxable Income.
When you exercise an ISO, you may have to include in
alternative minimum taxable income a portion of the fair market
value of the stock acquired through the exercise of the option. For
more information, see Form 6251, Alternative Minimum
Tax—Individuals, and its instructions.
Employee’s taxpayer identification number (TIN). For your
protection, this form may show only the last four digits of your
social security number (SSN), individual taxpayer identification
number (ITIN), or adoption taxpayer identification number (ATIN).
However, the employer has reported your complete TIN to the
IRS.
Account number. May show an account or other unique number
your employer or transfer agent assigned to distinguish your
account.

Box 1. Shows the date the option to purchase the stock was
granted to you.
Box 2. Shows the date you exercised the option to purchase the
stock.
Box 3. Shows the exercise price per share of stock.
Box 4. Shows the fair market value (FMV) of a share of stock on
the date the option was exercised.
Box 5. Shows the number of shares of stock transferred to you
pursuant to the exercise of the option.
Box 6. Shows the name, address, and TIN of the corporation
whose stock is being transferred (if other than the corporation
shown in TRANSFEROR boxes in the upper left corner of the
form).
Future developments. For the latest information about
developments related to Form 3921 and its instructions, such as
legislation enacted after they were published, go to
www.irs.gov/Form3921.

CORRECTED (if checked)
TRANSFEROR’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. October 2017)
TRANSFEROR’S TIN

EMPLOYEE’S TIN

3 Exercise price per share

$

EMPLOYEE’S name

4 Fair market value per share
on exercise date

$

Exercise of an
Incentive Stock
Option Under
Section 422(b)
Copy C
For Corporation

5 No. of shares transferred
6 If other than TRANSFEROR, name, address, and TIN of
corporation whose stock is being transferred

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code

This copy should
be retained by the
corporation whose
stock has been
transferred under
Section 422(b).

Account number (see instructions)
Form 3921 (Rev. October 2017)

(keep for your records)

www.irs.gov/Form3921

Department of the Treasury - Internal Revenue Service

VOID

CORRECTED

TRANSFEROR’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-2129

1 Date option granted

Form 3921
2 Date option exercised

(Rev. October 2017)
TRANSFEROR’S TIN

3 Exercise price per share

EMPLOYEE’S TIN

$

EMPLOYEE’S name

4 Fair market value per share
on exercise date

6 If other than TRANSFEROR, name, address, and TIN of
corporation whose stock is being transferred

City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 3921 (Rev. October 2017)

www.irs.gov/Form3921

Copy D
For Transferor

$

5 No. of shares transferred
Street address (including apt. no.)

Exercise of an
Incentive Stock
Option Under
Section 422(b)

For Privacy Act and
Paperwork
Reduction Act
Notice, see the
current version of
the General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Transferor
To complete Form 3921, use:
• the current General Instructions for Certain
Information Returns, and
• the current Instructions for Forms 3921 and 3922.
To order these instructions and additional forms, go
to www.irs.gov/Form3921.
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, 3922, or 5498 that you print from the IRS
website.
Due dates. Furnish Copy B of this form to the employee
by January 31 of the year following the year of exercise
of the ISO.

Furnish Copy C of this form to the corporation whose
stock is being transferred by January 31 of the year
following the year of exercise of the ISO.
File Copy A of this form with the IRS by February 28
of the year following the year of exercise of the ISO. If
you file electronically, the due date is March 31 of the
year following the year of exercise of the ISO. To file
electronically, you must have software that generates a
file according to the specifications in Pub. 1220. The
IRS does not provide a fill-in form option for Copy A.
Need help? If you have questions about reporting on
Form 3921, call the information reporting customer
service site toll free at 866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).