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printing these tax forms. 
 

Form 3921

(Rev. August 2013)

Cat. No. 41179O

Exercise of an 

Incentive Stock 

Option Under 

Section 422(b)

Copy A

For 

Internal Revenue 

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096.

OMB No. 1545-2129

For Privacy Act and 

Paperwork 

Reduction Act 

Notice, see the 

current version of

the General

Instructions for

Certain Information

Returns.

2525 VOID CORRECTED

TRANSFEROR'S name, street address, city or town, state or province, country, and 

ZIP or foreign postal code

TRANSFEROR'S federal identification number EMPLOYEE’S identification number

EMPLOYEE’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Date option granted

2 Date option exercised

3 Exercise price per share

$

4 Fair market value per share 

on exercise date

$

5 No. of shares transferred

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

corporation whose stock is being transferred

Form 3921 (Rev. August 2013) www.irs.gov/form3921

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

Form 3921

(Rev. August 2013)

Exercise of an 

Incentive Stock 

Option Under 

Section 422(b)

Copy B

For Employee

Department of the Treasury - Internal Revenue Service

OMB No. 1545-2129

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. 

CORRECTED (if checked)

TRANSFEROR'S name, street address, city or town, state or province, country, and 

ZIP or foreign postal code

TRANSFEROR'S federal identification number EMPLOYEE’S identification number

EMPLOYEE’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Date option granted

2 Date option exercised

3 Exercise price per share

$

4 Fair market value per share 

on exercise date

$

5 No. of shares transferred

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

corporation whose stock is being transferred

Form 3921 (Rev. August 2013) (keep for your records) www.irs.gov/form3921
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.

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 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).

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.
 

Form 3921

(Rev. August 2013)

Exercise of an 

Incentive Stock 

Option Under 

Section 422(b)

Copy C

For Corporation

Department of the Treasury - Internal Revenue Service

OMB No. 1545-2129

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 or town, state or province, country, and 

ZIP or foreign postal code

TRANSFEROR'S federal identification number EMPLOYEE’S identification number

EMPLOYEE’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Date option granted

2 Date option exercised

3 Exercise price per share

$

4 Fair market value per share 

on exercise date

$

5 No. of shares transferred

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

corporation whose stock is being transferred

Form 3921 (Rev. August 2013) (keep for your records) www.irs.gov/form3921
 

Form 3921

(Rev. August 2013)

Exercise of an 

Incentive Stock 

Option Under 

Section 422(b)

Copy D

For Transferor

Department of the Treasury - Internal Revenue Service

OMB No. 1545-2129

For Privacy Act and 

Paperwork 

Reduction Act 

Notice, see the 

current version of

the General

Instructions for

Certain Information

Returns.

VOID CORRECTED 

TRANSFEROR'S name, street address, city or town, state or province, country, and 

ZIP or foreign postal code

TRANSFEROR'S federal identification number EMPLOYEE’S identification number

EMPLOYEE’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Date option granted

2 Date option exercised

3 Exercise price per share

$

4 Fair market value per share 

on exercise date

$

5 No. of shares transferred

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

corporation whose stock is being transferred

Form 3921 (Rev. August 2013) www.irs.gov/form3921
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 or call 1-800-TAX-FORM 

(1-800-829-3676).

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, 

Specifications for Electronic Filing of Forms 1097, 1098, 

1099, 3921, 3922, 5498, 8935, and W-2G. The IRS does 

not provide a fill-in form option.

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). Persons with a hearing or speech 

disability with access to TTY/TDD equipment can call 

304-579-4827 (not toll free).