Form 3922 . . For calendar year
form | 3922 Transfer of Stock Acquired by Certain Options pened c
7 7 ‘or Corporation's
treesury Department! (¥4.S, Information Return Under section 6039(a)(2) of the Internal Revenue Code) 19... Record
1. Corpo- a. Name and address (including ZIP code) b. Employer identification number
ration
Whose
Stock Is
Being
Trans-
ferred
ind address (including ZIP code) ‘3. Date stock was transferred to transferor
7
4. Number of shares to which title is being
transferred
2 Trans- 5. Pla “X" in the appropriate box to in-
feror dicate whether the stock was acquired by

b. Identifying number:

option under:
a. Employee stock purchase
plan under section 423. . . . .C)

b. A restricted stock ption
under section 424 ... O

soir vrs GPO! 1968-0 319 084

Transfer of Stock Acquired by Certain Options
(U.S. Information Return Under section 6039(a)(2) of the Internal Revenue Code)

For calendar year Copy c
For Corporation's
19. Record

1. Corpo- | a. Name and address (including ZIP code) b. Employer identification number
Whose
Stock Is
Being
Trans-
ferred
‘a. Name and address (including ZIP code) 3, Date stock was transferred to transferor
T 7
4, Number of shares to which title is being
transferred
2 Trans- 5. Pl in “X"" in the appropriate box to In-
feror Sleste whether the stock was acquired by
option under
a. Employ; stock purchase
plan under section 423... . LJ
b. A restricted stock prtion
b. Identifying number: under section 424 ... O
oir POF 1964-0 819 084
Form 3922 For calendar year Copy C

(Rev. Oct, 1968)
U.S. Treasury Department]
ial Revenue Servi

Transfer of Stock Acquired by Certain Options
(U.S. Information Return Under section 6039(a)(2) of the Internal Revenue Code)

For Corporation's
19........ Record

1. Corpo- | a. Name and address (including ZIP code) b. Employer identification number
ration
‘Whose
Stock is
Being
Trans-
ferred
a. Name and address (including ZIP code) ‘3. Date stock was transferred to transferor
cr 7
4. Number of shares to which title is being
transferred
2 Trans- §. Place an “X" in the appropriate box to in-
feror dicate whether the stock was acquired by
option uni
a. Em

'b. Identifying number:

ipo; stock purchase
plan under section 423. . . . .C)

b. A restricted stock petion
under section 424 ... O

‘Yotrtese GPO! 1968-0 319 084




Instructions

Who Must File—Every corporation which records (or has its agent
record) a transfer of the title of stock which was acquired through the
exercise, on or after January 1, 1964, of (a) an option which was granted
under an employee stock purchase plan described in section 423(b) and
to which the rule in section 423(c) (where option price is between 85
percent and 100 percent of value of stock) applies, or (b) a restricted
stock option described in section 424(b) and to which the rule in section
424(c)(1) (where option price is between 85 percent and 95 percent of
value of stock) applies. A return is only required for this first recorded
transfer of stock. When stock is originally issued to the optionee and
another person or persons as joint tenants, or as tenants by the entirety
and a stock certificate was not previously actually issued to the optionee
as a sole owner, a return is required with respect to the first transfer of
the title to such stock (or of his interest therein).

Where To File—See Form 4067 for list of Internal Revenue Service
Centers. Form 4067 is a summary report used to transmit Forms 3921
and 3933 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 Transferor.—Every corporation making this return shall

furnish a copy to each transferor whose name or identifying number is (or
should be) shown on such return.

Time for Furnishing Statement.—The statement required to be fur-
nished to any transferor for a calendar year shall be furnished to him
on or before January 31 of the following year.

Extension of Time for Furnishing Statement.—Your District Director, or
service center director with whom you file your income tax return, 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 director in determining the period
of the extension, if any, which will be granted. A letter to the director
signed by the applicant (or its agent) will suffice as an application. The ap-
plication 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 transferor if it is
mailed to him at his last known address.

Identification of Stock.—Every corporation which transfers any share
of stock pursuant to the exercise of an option described in section 6039
(a)(2), shall identify such stock in a manner sufficient to enable the
accurate reporting of the transfer of record title to such shares. Such
identification may be accomplished by assigning to the certificates of
stock issued pursuant to the exercise of such options a special serial
number, or color.

‘estes U.S. GOVERNMENT PRINTING OFFICE : 1968—-O-319-084

Instructions

Who Must File—Every corporation which records (or has its agent
record) a transfer of the title of stock which was acquired through the
exercise, on or after January 1, 1964, of (a) an option which was granted
under an employee stock purchase plan described in section 423(b) and
to which the rule in section 423(c) (where option price is between 85
percent and 100 percent of value of stock) applies, or (b) a restricted
stock option described in section 424(b) and to which the rule in section
424(c)(1) (where option price is between 85 percent and 95 percent of
value of stock) applies. A return is only required for this first recorded
transfer of stock. When stock is originally issued to the optionee and
another person or persons as joint tenants, or as tenants by the entirety
and a stock certificate was not previously actually issued to the optionee
as a sole owner, a return is required with respect to the first transfer of
the title to such stock (or of his interest therein).

Where To File—See Form 4067 for list of Internal Revenue Service
Centers. Form 4067 is a summary report used to transmit Forms 3921
and 3933 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 Transferor.—Every corporation making this return shall

furnish a copy to each transferor whose name or identifying number is (or
should be) shown on such return.

Time for Furnishing Statement.—The statement required to be fur-
nished to any transferor for a calendar year shall be furnished to him
on or before January 31 of the following year.

Extension of Time for Furnishing Statement.—Your District Director, or
service center director with whom you file your income tax return, 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 director in determining the period
of the extension, if any, which will be granted. A letter to the director
signed by the applicant (or its agent) will suffice as an application. The ap-
plication 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 transferor if it is
mailed to him at his last known address.

Identification of Stock—Every corporation which transfers any share
of stuck pursuant to the exercise of an option described in section 6039
(a)(2), shall identify such stock in a manner sufficient to enable the
accurate reporting of the transfer of record title to such shares. Such
identification may be accomplished by assigning to the certificates of
stock issued pursuant to the exercise of such options a special serial
number, or color.

‘evesro U.S, GOVERNMENT PRINTING OFFICE : 1968-O-319-084

Instructions

Who Must File—Every corporation which records (or has its agent
record) a transfer of the title of stock which was acquired through the
exercise, on or after January 1, 1964, of (a) an option which was granted
under an employee stock purchase plan described in section 423(b) and
to which the rule in section 423(c) (where option price is between 85
percent and 100 percent of value of stock) applies, or (b) a restricted
stock option described in section 424(b) and to which the rule in section
424(c)(1) (where option price is between 85 percent and 95 percent of
value of stock) applies. A return is only required for this first recorded
transfer of stock. When stock is originally issued to the optionee and
another person or persons as joint tenants, or as tenants by the entirety
and a stock certificate was not previously actually issued to the optionee
as a sole owner, a return is required with respect to the first transfer of
the title to such stock (or of his interest therein).

Where To File-—See Form 4067 for list of Internal Revenue Service
Centers. Form 4067 is a summary report used to transmit Forms 3921
and 3933 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 Transferor—Every corporation making this return shall

furnish a copy to each transferor whose name or identifying number is (or
should be) shown on such return.

Time for Furnishing Statement.—The statement required to be fur-
nished to any transferor for a calendar year shall be furnished to him
on or before January 31 of the following year.

Extension of Time for Furnishing Statement.—Your District Director, or
service center director with whom you file your income tax return, 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 director in determining the period
of the extension, if any, which will be granted. A letter to the director
signed by the applicant (or its agent) will suffice as an application. The ap-
plication 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 transferor
mailed to him at his last known address.

Identification of Stock.—Every corporation which transfers any share
of stock pursuant to the exercise of an option described in section 6039
(a)(2), shall identify such stock in a manner sufficient to enable the
accurate reporting of the transfer of record title to such shares. Such
identification may be accomplished by assigning to the certificates of
stock issued pursuant to the exercise of such options a special serial
number, or color.

‘etedeo U.S, GOVERNMENT PRINTING OFFICE : 1968~O-319-084


Fe 3922 . For calendar year
rom | 3922 Transfer of Stock Acquired by Certain Options Copy A
1S. " ‘or nal
internal Rerange Semmes] (U.S. Information Return Under section 6039(a)(2) of the Internal Revenue Code) 19... eee Revenue Service
1 Cape. [ a. Name and address (including 21P code) . Employer Identification number
ration
Whose
Stock Is
Being
Trans-
‘a. Name and address (including ZIP code) 3. Date stock was transferred to transferor
T 7
‘4. Number of shares to which title Is being
transferred
2 Trans- 8. Place an "2" In the appropriate box to in-
feror icate wh r the stock was acquired by
option trae
© Fah ender section'ass, . . . JO
b. A restricted stock pption
b. Identifying number: under section 424 .. O
Feri oPo eer -o-s 10-008
form 3922 , — For calendar year
ro Transfer of Stock Acquired by Certain Options Copy A
7 a ‘or ferni
Gaternal Roeser Semen'! (U.S. Information Return Under section 6039(a)(2) of the Internal Revenue Code) 19... Revenue Service
1. Capo |. Name and address (including ZIP code) b. Employer identification number
ration
Whose
Stock is
Being
Trans-
ferred
a. Name and address (including ZIP code) 3. Date stock was transferred to transferor
T 7
4. Number of shares to which title Is being
transferred
2. Trans- %. Place an “X” in the appropriate box to In-
feror dics ‘whether the stock was acquired by
option under
© Fan titer sector aes... JO
b. A restricted stock pption
b. Identifying number: under section 424 . 2
Fririvk oro tes-o-810-004
Fe 3922 : . . For calendar year
Form | 3922 Transfer of Stock Acquired by Certain Options Copy A
7 se or Interna!
4S. Treasury Department! (41S, Information Return Under section 6039(a)(2) of the Internal Revenue Code) 19........ Revenue Service

b. Employer identification number

1, Corpo- a. Name and address (including ZIP code)
ration
Whose
Stock is
Being
Trans-
ferred
a. Name and address (including ZIP code) ‘3. Date stock was transferred to transferor
i 7
4. Number of shares to which title Is being
transferred
2. Trans- 5. in “X"" In the appropriate box to In-
feror Whether the stock was acquired by
option unde
8, Employee stock purchase
plan under section 428... . .L1

b. Identifying number:

b. A restricted stosk option
under section

. O

ete t ty GPO 1 1968-0-319-084




Form

(Rev. Oct. 1968)
U.S. Treasury Department]
Internal Revenue Service

3922 Transfer of Stock Acquired by Certain Options

(U.S. Information Return Under section 6039(a)(2) of the Internal Revenue Code)

For calendar year Copy B
For Transferor
19........ of Stock

1. Corpo- a. Name and address (including ZIP code) b. Employer identification number
ration
‘Whose
Stock is
Being
Trans-
ferred
a. Name and address (including ZIP code) 3. Date stock was transferred to transferor
r 7
4. Number of shares to which title Is being
transferred
2, Trans- . in tl riate box to In-
feror 5 ine ee has ‘acauired OY
option under:
Empl ok hi
® plan under section 423 = O
b. A restricted stock pption
b. Identifying number: under section 426 Oo
tetetr te GPO; 1969-O-319-084
Forn 3922 . . . For calendar year
fae cn 196% Transfer of Stock Acquired by Certain Options copy B
‘Oe it] 7 ‘or Transferor
U.S Tressury Deparment] (U.S, Information Return Under section 6039(a)(2) of the Internal Revenue Code) 19........ ‘of Stock

1, Corpo- a. Name and address (including ZIP code) b. Employer identification number
ration
‘Whose
Stock is
Being
Trans-
ferred
a. Name and address (including ZIP code) 3. Date stock was transferred to transferor
r 7q
4. Number of shares to which title is being
transferred
2. Trans- 5. Place an “X” in the appropriate box to In-
feror dicate whether the stock was ired by
option under
Empl stock hi
® Blan under section 423° O
b. A restricted stock pption
b. Identifying number: Under section 424 O
weirserr GPO: 1968—-0-319-084
form 3922 . . For calendar year
aon Transfer of Stock Acquired by Certain Options : Copy 8
. ‘or Transferor
ary Department! (4,6, Information Return Under section 6039(a)(2) of the Internal Revenue Code) 19... ‘of Stock

‘a, Name and address (including ZIP code)

b. Employer identification number

2. Trans-
feror

‘a. Name and address (including ZIP code)

r

‘3. Date stock was transferred to trai

b. Identifying number:

“4. Number of shares to which title is being
transferred
5. lace an “X" in the appropriate box to In-
Sleste whether t by
option nde
a. Emi tock purch:
plan under section 42 OO
b. A restricted stock pption
under section 424 O

‘Year tere GPO: 196¢-0-319-084