Form 3921 (Rev. October 2017) F3921
User Manual: 3921
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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 downloaded and printed and used to satisfy the requirement to provide the information to the recipient. To order official IRS information returns, which include a scannable Copy A for filing with the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on Employer and Information Returns, and we’ll mail you the forms you request and their instructions, as well as any publications you may order. Information returns may also be filed electronically using the IRS Filing Information Returns Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act Information Returns (AIR) program (visit www.IRS.gov/AIR). See IRS Publications 1141, 1167, and 1179 for more information about printing these tax 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).
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