Form 3922 Transfer of Stock Acquired Through an Employee Stock Pur

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VOID

CORRECTED

CORPORATION’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 3922
2 Date option exercised

(Rev. October 2024)
CORPORATION’S federal identification number EMPLOYEE’S identification number

3 Fair market value per share
on grant date

Transfer of Stock
Acquired Through
an Employee
Stock Purchase
Plan Under
Section 423(c)

4 Fair market value per share
on exercise date

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 5, 2024
DO NOT FILE
$

EMPLOYEE’S name

5 Exercise price paid per share

$

6 No. of shares transferred

$

7 Date legal title transferred

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

8 Exercise price per share determined as if the option was
exercised on the date shown in box 1

Account number (see instructions)

$

Form 3922 (Rev. 10-2024)

Cat. No. 41180P

www.irs.gov/Form3922

Copy A

For
Internal Revenue
Service Center

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Paperwork Reduction
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General Instructions
for Certain
Information Returns.
www.irs.gov/Form1099

Department of the Treasury - Internal Revenue Service

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CORRECTED
CORPORATION’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 3922
2 Date option exercised

(Rev. October 2024)
CORPORATION’S federal identification number EMPLOYEE’S identification number

3 Fair market value per share
on grant date

Transfer of Stock
Acquired Through
an Employee
Stock Purchase
Plan Under
Section 423(c)

4 Fair market value per share
on exercise date

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 5, 2024
DO NOT FILE
$

EMPLOYEE’S name

5 Exercise price paid per share

$

6 No. of shares transferred

$

7 Date legal title transferred

Street address (including apt. no.)

Copy B

For Employee

This is important tax
information and is
being furnished to
the Internal Revenue
Service.

City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)

8 Exercise price per share determined as if the option was
exercised on the date shown in box 1

$

Form 3922 (Rev. 10-2024)

(keep for your records)

www.irs.gov/Form3922

Department of the Treasury - Internal Revenue Service

Instructions for Employee
You have received this form because (1) your employer (or its
transfer agent) has recorded a first transfer of legal title of
stock you acquired pursuant to your exercise of an option
granted under an employee stock purchase plan, and (2) the
exercise price was less than 100% of the value of the stock on
the date shown in box 1 or was not fixed or determinable on
that date.
No income is recognized when you exercise an option
under an employee stock purchase plan. However, 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.
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 fair market value (FMV) per share on the
date the option to purchase the stock was granted to you.
Box 4. Shows the FMV per share on the date you exercised
the option to purchase the stock.
Box 5. Shows the price paid per share on the date you
exercised the option to purchase the stock.
Box 6. Shows the number of shares to which legal title was
transferred by you.
Box 7. Shows the date legal title of the shares was first
transferred by you.
Box 8. If the exercise price per share was not fixed or
determinable on the date entered in box 1, box 8 shows the
exercise price per share determined as if the option was
exercised on the date in box 1. If the exercise price per share
was fixed or determinable on the date shown in box 1, then
box 8 will be blank.
Future developments. For the latest information about
developments related to Form 3922 and its instructions, such
as legislation enacted after they were published, go to
www.irs.gov/Form3922.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 5, 2024
DO NOT FILE