ror 3921 | Exercise of a Qualified or Restricted Stock Option Copy C

(Rev. Aug. 1967) i i i
U.S. Treasury Department (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Transferor of Stock
Internal Revenue Service for calendar year 19...

1(a). Name and address (including ZIP code) of corporation transferring stock

| (b) Employer identification number

| (b) Identifying number

2(a). Name and address (including ZIP code) of person to whom transferred

3. Name of the corporation whose stock is transferred (If different from the corporation transferring stock)

4. Date option granted 5. Date of transfer | 6. Fair market value of stock at

| time option exercised

7. Number of shares transferred

|
8. Check whether the option exercised is:
(a) A qualified stock option under section 422(b) ]_(b) A restricted stock option under section 424(b) 1)

rorm 3921 | Exercise of a Qualified or Restricted Stock Option Copy C

(Rev. Aug. 1967) , i i

U.S. Treasury Department (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Transferor of Stock

Internal Revenue Service for calendar year 19...

1(@). Name and address (including ZIP code) of corporation transferring stock | (b) Employer identification number
|

2(a). Name and address (including ZIP code) of person to whom transferred | (b) Identifying number

3. Name of the corporation whose stock is transferred (If different from the corporation tra _

4. Date option granted 5. Date of transfer -—=—~=|:~«G. Fair market value of stock at | 7. Number of shares transferred

time option exercised

8. Check whether the option exercised is:
(a) A qualified stock option under section 422(b) []_ (b) Arestricted stock option under section 424(b) 1

rom 3921 | Exercise of a Qualified or Restricted Stock Option Copy C

(Rev. Aug. 1967) i i i
U.S. Treasury Department (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Transferor of Stock
Internal Revenue Service for calendar year 19....

— I (®) Identifying number

1(a). Name and address (including ZIP code) of corporation transferring stock | (b) Employer identification number
|
i

~ _ — _ |

Jame and address (including ZIP code) of person to whom transferred

inose stock is transferred ({f different from the corporation transferring stack)

4. Date option granted | 5. Date of transfer 6. Fair market value of stock at | 7. Number of shares transferred
time option exercised |
\ j

8. Check whether the option exercised is:
(@) A qualified stock option under section 422(b) ]_(b) A restricted stock option under section 424(b) C1





INSTRUCTIONS

Who Must File.—Every corporation which transfers a share of
stock to any person pursuant to such person’s exercise of a qualified
stock option described in section 422(b), or a restricted stock option
described in section 424(b).

Where To File.—See Form 4067 for list of Service Centers. Form
4067 is a summary report used to transmit Forms 3921 and 3922 to
the Service Centers.

When To File.—This return must be filed for the calendar year
on or before February 28 of the following year.

Statement to the Person Exercising the Option.—Every corpo-
ration making this return shall furnish to each person whose name
and identifying number is shown on such return a copy of this return.

Time for Furnishing Statement.—The statement required to be
furnished to any person for a calendar ycar shall be furnished to
such person on or before January 31 of the following year.

Extension of Time for Furnishing Statement.—Your district
director may grant an extension of time not exceeding 30 days in
which to furnish such statements. The application must contain a
full recital of the reasons for requesting the extension to aid the
district director in determining the period of the extension, if any,
which will be granted. A letter to the district director signed by the
applicant will suffice as an application. The application must be
filed on or before January 31 of the year following the calendar
year for which the form is filed.

A statement shall be considered to be furnished to a person if it
is mailed to such person at his last known address.

‘eveetr US. GOVERNMENT PRINTING OFFICE :1987~O-271-503

INSTRUCTIONS

Who Must File.—Every corporation which transfers a share of
stock to any person pursuant to such person’s exercise of a qualified
stock option described in section 422(b), or a restricted stock option
described in section 424(b).

Where To File.—See Form 4067 for list of Service Centers. Form
4067 is a summary report used to transmit Forms 3921 and 3922 to
the Service Centers.

When To File.—This return must be filed for the calendar year
on or before February 28 of the following year.

Statement to the Person Exercising the Option.—Every corpo-
ration making this return shall furnish to each person whose name
and identifying number is shown on such return a copy of this return.

Time for Furnishing Statement.—The statement required to be
furnished to any person for a calendar year shall be furnished to
such person on or before January 31 of the following year.

Extension of Time for Furnishing Statement.—Your district
director may grant an extension of time not exceeding 30 days in
which to furnish such statements. The application must contain a
full recital of the reasons for requesting the extension to aid the
district director in determining the period of the extension, if any,
which will be granted. A letter to the district director signed by the
applicant will suffice as an application. The application must be
filed on or before January 31 of the year following the calendar
year for which the form is filed.

A statement shall be considered to be furnished to a person if it
is mailed to such person at his last known address.

‘Yeve ses US, GOVERNMENT PRINTING OFFICE : 1957~0-271-503

INSTRUCTIONS

Who Must File-—Every corporation which transfers a share of
stock to any person pursuant to such person’s exercise of a qualified
stock option described in section 422(b), or a restricted stock option
described in section 424(b).

Where To File.—See Form 4067 for list of Service Centers, Form
4067 is a summary report used to transmit Forms 3921 and 3922 to
the Service Centers,

When To File.—This return must be filed for the calendar year
on or before February 28 of the following year.

Statement to the Person Exercising the Option.—Every corpo-
ration making this return shall furnish to each person whose name
and identifying number is shown on such return a copy of this return.

Time for Furnishing Statement.—The statement required to be
furnished to any person for a calendar year shall be furnished to
such person on or before January 31 of the following year.

Extension of Time for Furnishing Statement.—Your district
director may grant an extension of time not exceeding 30 days in
which to furnish such statements. The application must contain a
full recital of the reasons for requesting the extension to aid the
district director in determining the period of the extension, if any,
which will be granted. A letter to the district director signed by the
applicant will suffice as an application. The application must be
filed on or before January 31 of the year following the calendar
year for which the form is filed.

A statement shall be considered to be furnished to a person if it
is mailed to such person at his last known address,

‘evewealr U.S. GOVERNMENT PRINTING OFFICE :1967~-0-271-803


rorm 3921 | Exercise of a Qualified or Restricted Stock Option Copy A

(Rev. Aug. 1967) U.S. information return under Section 6039(a)(1) of the Internal Revenue Code)
U.S. Treasury Department] can(uy ) For Internal Revenue Service
Internal Revenue Service for calendar year 19....
1(a). Name and address (including ZIP code) of corporation transferring stock (b) Employer identification number
2(a). Name and address (including ZIP code) of person to whom transferred | (b) Identifying number _

3. Name of the corporation whose stock is transferred (If different from the corporation transferring stock)

| 6. Fair market value of stock at
| time option exercised

4. Date option granted 7 5. Date of transfer 7. Number of shares transferred

8. Check whether the option exercised is:
(a) A qualified stock option under section 422(b) 1. (b) A restricted stock option under section 424(b)

rorm 3921 | Exercise of a Qualified or Restricted Stock Option Copy A

(Rev. Aug. 1967) | (U.S, information return under Section 6039(a)(1) of the Internal Revenue Code) F
U.S. Treasury Department] For Internal Revenue Service
Internal Revenue Service for calendar year 19.....

1(@). Name and address (including ZIP code) of corporation transferring stock | (b) Employer identification number
2(a). Name and address (including ZIP code) of person to whom transferred (b) Identifying number a

4. Date option granted | 5. Date of transfer ~~ ""6. Fair market value of stock at 7. Number of shares transferred
time option exercised

8. Check whether the option exercised is:
(a) A qualified stock option under section 422(b) 1] (b) Arrestricted stock option under section 424(b)

rorm 3921 | Exercise of a Qualified or Restricted Stock Option Copy A

(Rev, Aug. 1967) U.S. information return under Section 6039(a)(1) of the Internal Revenue Code! .
U.S. Treasury Department] ¢ (ay(2) J For Internal Revenue Service
Internal Revenue Service for calendar year 19.....

1(a). Name and address (including ZIP code) of corporation transferring stock (b) Employer identification number

— . | _ _
| (b) Identifying number
|

"2(a). Name and address (including ZIP code) of person to whom

3. Name of the corporation whose stock is transferred (If different from the corporation transferring stock)

4. Date option granted | 5: Date of transfer "6. Fair market value of stock at | 7. Number of shares transferred
time option exercised

8. Check whether the option exercised is:
(a) A qualified stock option under section 422(b) 1 (b) Arrestricted stock option under section 424(b) C)





rorw 3921 | Exercise of a Qualified or Restricted Stock Option Copy B

(Rev. Aug. 1967) U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) wt .
U.S. Treasury Department} (ay) ) For Person Exercising Option
Internal Revenue Service for calendar year 19.

1(a). Name and address (including ZIP code) of corporation transferring stock (b) Employer identification number
i
2(a). Name and address (including ZIP code) of person to whom transferred 1b) Identifying number

3, Name of the corporation whose stock is transferred (If different from the corporation transferring stock)

4. Date option granted 5. Date of transfer 6. Fair market value of stock at | 7. Number of shares transferred
time option exercised

| | |
8. Check whether the option exercised is:
(a) A qualified stock option under section 422(b) 1] (b) A restricted stock option under section 424(b) 0

rorm 3921 | Exercise of a Qualified or Restricted Stock Option Copy B

(Rev. Aug. 1967) : i i
U.S, Treasury Department (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Person Exercising Option
Internal Revenue Service for calendar year 19...

1(a). Name and address (including ZIP code) of corporation transferring stock | (b) Employer identification number

2(a). Name and address (including ZIP code) of person to whom transferred (b) Identifying number

3, Name of the corporation whose stock is transferred (If different from the corporation transferring stock)

4. Date option granted 5. Date of transfer | 6. Fair market value of stock at | 7. Number of shares transferred
1 time option exercised

! - ~ -
8. Check whether the option exercised is:
(a) A qualified stock option under section 422(b) []_ (b) A restricted stock option under section 424(b) C1]

rorw 3921 | Exercise of a Qualified or Restricted Stock Option Copy B

(Rev, Aug. 1967) (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code)

U.S. Treasury Department For Person Exercising Option
internal Revenue Service for calendar year 19........

1(a). Name and address (including ZIP code) of corporation transferring stock (b) Employer identification number

2(@). Name and address (including ZIP code) of person to whom transferred ~'(b) Identifying number

3, Name of the corporation whose stock is transferred (If different from the corporation transferring stock)

4. Date option granted 5. Date of transfer | 6. Fair market value of stock at 7. Number of shares transferred
time option exercised

8. Check whether the option exercised
(a) A qualified stock option under section 422(b) []__(b) Arestricted stock option under section 424(b) L]