scannable forms and other products. 

See IRS Publications 1141, 1167, 1179 and other IRS resources for information 

about printing these tax forms. 
CORRECTED

TRANSFEROR’S name, street address, city, state, and ZIP code OMB No. 1545-2129 1

2 Date option exercised

TRANSFEROR’S federal identification number EMPLOYEE’S identification number Fair market value per

share on exercise date

3 Exercise price per share 4

EMPLOYEE’S name

If other than TRANSFEROR, name, address, and EIN of

corporation whose stock is being transferred

Street address (including apt. no.) 6

City, state, and ZIP code

Account number (see instructions)

Form 3921 (Rev. October 2010) Department of the Treasury - Internal Revenue Service

2525 VOID

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Cat. No. 41179O

Form 3921

Exercise of an

Incentive Stock 

Option Under

Section 422(b)

5

Copy A

For

Internal Revenue

Service Center No. of shares transferred

$

(Rev. October 2010)

Date option granted

$

For Privacy Act and

Paperwork

Reduction Act

Notice, see the most

current version of

the General

Instructions for

Certain Information

Returns.

File with Form 1096.
Form 3921 (Rev. October 2010) Department of the Treasury - Internal Revenue Service

Copy B

This is important tax

information and is

being furnished to the

Internal Revenue

Service. 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.

(keep for your records)

For Employee

CORRECTED (if checked)

TRANSFEROR’S name, street address, city, state, and ZIP code OMB No. 1545-2129 1

2 Date option exercised

TRANSFEROR’S federal identification number EMPLOYEE’S identification number Fair market value per

share on exercise date

3 Exercise price per share 4

EMPLOYEE’S name

If other than TRANSFEROR, name, address, and EIN of

corporation whose stock is being transferred

Street address (including apt. no.) 6

City, state, and ZIP code

Account number (see instructions)

Form 3921

Exercise of an

Incentive Stock 

Option Under

Section 422(b)

5 No. of shares transferred

$

(Rev. October 2010)

Date option granted

$
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.

Account number. May show an account or other

unique number your employer or transfer agent

assigned to distinguish your account.

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 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 6. Shows the name, address, and employer

identification number (EIN) 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).

Box 3. Shows the exercise price per share of stock.

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.
Copy C

For Corporation

Exercise of an

Incentive Stock 

Option Under

Section 422(b)

This copy should

be retained by the

corporation whose

stock has been

transferred under

Section 422(b).

CORRECTED (if checked)

TRANSFEROR’S name, street address, city, state, and ZIP code OMB No. 1545-2129 1

2 Date option exercised

TRANSFEROR’S federal identification number EMPLOYEE’S identification number Fair market value per

share on exercise date

3 Exercise price per share 4

EMPLOYEE’S name

If other than TRANSFEROR, name, address, and EIN of

corporation whose stock is being transferred

Street address (including apt. no.) 6

City, state, and ZIP code

Account number (see instructions)

Form 3921 (Rev. October 2010) (keep for your records) Department of the Treasury - Internal Revenue Service

Form 3921

5 No. of shares transferred

$

(Rev. October 2010)

Date option granted

$
CORRECTED

Form 3921 (Rev. October 2010) Department of the Treasury - Internal Revenue Service

VOID

Copy D

For Transferor

Exercise of an

Incentive Stock 

Option Under

Section 422(b)

For Privacy Act and

Paperwork

Reduction Act

Notice, see the

most current

version of the

General

Instructions for

Certain Information

Returns.

TRANSFEROR’S name, street address, city, state, and ZIP code OMB No. 1545-2129 1

2 Date option exercised

TRANSFEROR’S federal identification number EMPLOYEE’S identification number Fair market value per

share on exercise date

3 Exercise price per share 4

EMPLOYEE’S name

If other than TRANSFEROR, name, address, and EIN of

corporation whose stock is being transferred

Street address (including apt. no.) 6

City, state, and ZIP code

Account number (see instructions)

Form 3921

5 No. of shares transferred

$

(Rev. October 2010)

Date option granted

$
Instructions for Transferor

General and specific form instructions are provided as

separate products. The products you should use to

complete Form 3921 are the most current General

Instructions for Certain Information Returns and the

most current Instructions for Forms 3921 and 3922. A

chart in the general instructions gives a quick guide to

which form must be filed to report a particular

payment. To order these instructions and additional

forms, visit IRS.gov or call 1-800-TAX-FORM

(1-800-829-3676).

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.

Caution: Because paper forms are scanned during

processing, you cannot file with the IRS Forms

1096, 1097, 1098, 1099, 3921, 3922, or 5498 that you

print from the IRS website.

Need help? If you have questions about reporting on

Form 3921, call the information reporting customer

service site toll free at 1-866-455-7438 or

304-263-8700 (not toll free). For TTY/TDD equipment,

call 304-579-4827 (not toll free). The hours of

operation are Monday through Friday from 8:30 a.m. to

4:30 p.m., Eastern time.

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 electroncially, 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,

Specifications for Filing Forms 1097, 1098, 1099, 3921,

3922, 5498, 8935, and W-2G Electronically. IRS does

not provide a fill-in form option.