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

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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 2024)
TRANSFEROR’S TIN

EMPLOYEE’S TIN

3 Exercise price per share

4 Fair market value per share
on exercise date

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

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 6, 2024
DO NOT FILE
$

EMPLOYEE’S name

$

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)

Copy A

For
Internal Revenue
Service Center

For filing information,
Privacy Act, and
Paperwork Reduction
Act Notice, see the
General Instructions
for Certain
Information Returns.
www.irs.gov/Form1099

Form 3921 (Rev. October 2024)

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

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 2024)
TRANSFEROR’S TIN

EMPLOYEE’S TIN

3 Exercise price per share

4 Fair market value per share
on exercise date

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

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 6, 2024
DO NOT FILE
$

EMPLOYEE’S name

$

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 2024)

(keep for your records)

www.irs.gov/Form3921

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.

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 FMV of a share of stock on the date the option
was exercised.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 6, 2024
DO NOT FILE

When you exercise an ISO, you may have to include in
alternative minimum taxable income a portion of the fair market
value (FMV) 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 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.
Free File Program. Go to www.irs.gov/FreeFile to see if you
qualify for no-cost online federal tax preparation, e-filing, and
direct deposit or payment options.

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 2024)
TRANSFEROR’S TIN

EMPLOYEE’S TIN

3 Exercise price per share

4 Fair market value per share
on exercise date

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

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 6, 2024
DO NOT FILE
$

EMPLOYEE’S name

$

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
Account number (see instructions)
Form 3921 (Rev. October 2024)

(keep for your records)

www.irs.gov/Form3921

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

Department of the Treasury - Internal Revenue Service