rorw 3921 EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION Copy C

(Rev, Oct, 1965)

.S. it ic Section 60:
us. _Treaury Deptmet (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Transferor of Stock
for calendar year 19_____-
1(a). Name and address of corporation transferring stock (b) Employer identification number
2(a). Name and address of person to whom transferred (b) Identifying number

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

A, 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) C]
(b) A restricted stock option under section 424 (b) 1

orn 3921 EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION Copy C

(Rev. Oct. 1965)

US. Tesry Dotan (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Transferor of Stock
for calendar year 19.....-
1(a). Name and address of corporation transferring stock (6) Employer identification number
2(a). Name and address 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 is:
(a) A qualified stock option under section 422 (b)
(b) A restricted stock option under section 424 (b) 1)

ror 3921 EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION Copy C

(Rev. Oct. 1965)

vs Ter Denainent (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Transferor of Stock
for calendar year 19.....-
1(a). Name and address of corporation transferring stock | (6) Employer identification number

2(a), Name and address 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 is:
(a) A qualified stock option under section 422 (b) [J
(b) A resiticted stock option under section 424 (b) CI





INSTRUCTIONS

Who Must File—Every corporation which transfers a share of stock
to any person pursuant to such person's exercise on or after January 1,
1964, 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 corporation
making this return shall furnish to each person whose name and identi-
fying number is shown on such return a copy of this return.

Time for Furnishing Statement—The statement required to be fur-
nished 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.—The district director
with whom the income tax returns of the applicant corporation are
filed 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 appli-
cant 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.

‘Sever U.S. GOVERNMENT PRINTING OFFICE: 1955—-O-789-425,

INSTRUCTIONS

Who Must File—Every corporation which transfers a share of stock
to any person pursuant to such person’s exercise on or after January 1,
1964, 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 corporation
making this return shall furnish to each person whose name and identi-
fying number is shown on such return a copy of this return.

Time for Furnishing Statement.—The statement required to be fur-
nished 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—The district director
with whom the income tax returns of the applicant corporation are
filed 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 appli-
cant 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.

eveder US. GOVERNMENT PRINTING OFFICE: 1985—0-789-425

INSTRUCTIONS

Who Must File—Every corporation which transfers a share of stock
to any person pursuant to such person’s exercise on or after January 1,
1964, 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 392] 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 corporation
making this return shall furnish to each person whose name and identi-
fying number is shown on such retum a copy of this return,

Time for Furnishing Statement.—The statement required to be fur-
nished 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—The district director
with whom the income tax returns of the applicant corporation are
filed 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 appli-
cant 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.

‘Severo U.S. GOVERNMENT PRINTING OFFICE: 1985—-O-789-425,


Form 3921
(Rev. Oct. 1965)
US. Treasury Department
Internal Revenue Service

EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION

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

for calendar year 19.

Copy A
For Internal Revenue Service

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

2(@). Name and address of person to whom transferred

~ | (&) Identifying number

(6) Employer identification 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 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) [)
(b) A restricted stock option under section 424 (6) 0

Form 3921
(Rev. Oct, 1965)

U.S. Treasury Department
Internal Revenue Service

EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION

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

for calendar year 19.

Copy A
For Internal Revenue Service

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

(b) Employer identification number

2(a). Name and address 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 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) 0)
(b) A restricted stock option under section 424 (b) 1

Form 3921
(Rev. Oct, 1965)
US, Treasury Department
Internal evens’ Service

EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION

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

for calendar year 19

Copy A
For Internal Revenue Service

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

(b) Employer identification number

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

(6) 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 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) 0
(b) A restricted stock option under section 424 (b) []





rorm 3921 EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION Copy B

(Rev. Oct. 1965) 5 i i
us Us. Tesmry Dorgan (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Person Exercising Option

for calendar year 19.-.---
1(a). Name and address of corporation transferring stock

(6) Employer identification number

2(a). Name and address 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 is:
(a) A qualified stock option under section 422(b) 1
(b) A restricted stock option under section 424(b) 1)

rorw 3921 EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION Copy B

(Rev. Oct. 1965) : :
u us. Tessy Denar (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Person Exercising Option

for calendar year 19,

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

2(a). Name and address 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 is:
(a) A qualified stock option under section 422 (b) 1
(b) A restricted stock option under section 424 (b) 1)

(Rev. Oct. 1965) i
vs. Tray Deranent (U.S. information return under Section 6039(a)(1) of the Internal Revenue Code) For Person Exercising Option

for calendar year 19.

rorm 3921 EXERCISE OF A QUALIFIED OR RESTRICTED STOCK OPTION Copy B

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

2(a). Name and address of person to whom transferred (6) 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)
(b) A restricted stock option under section 424 (b) 1