Form 3922 , 7 For calendar year 0
teow, Sept 1978) Transfer of Stock Acquired by Certain Options ro ee
Department of the geeasury | (U.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
‘a. Name and address (including ZIP code) 3. Date stock was transferred to transferor
cf Sumber of shares to which title is being
ransferre
T- 7
T 5. Place an “X" in the appropriate box to in-
rans- dicate whether the stock was acquired by
feror option under:
a. Employee stock purchase Oo
plan ui section 423. . . .
BRA tricted stock optic
tinder section sean... CL)
b. Identifying number:

“fr USS, GOVERNMENT PRINTING OFFICE : 197—O-263-479




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 de-
scribed 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 cwner, a return is re-
quired with respect to the first transfer of the title to such stock
(or of his interest therein).

Where to File.—See the instructions for your income tax re-
turn for a listing of the Service Cence: where Farm: 2322 can be
filed.

When to File.—This return must be filed for the ca'endar 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 a copy of this return to

each person whose name and identifying number is shown on
such return, on or before January 31, of the year following the
year for which the return is required.

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

Extension of Time for Furnishing Statement.—Your District
Director, or service center director with whom you file your in-
come 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 ex-
tension to aid the director in determining the period of the exten-
sion, if any, which will be granted. A letter to the director signed
by the applicant (or its agent) 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

Identification of Stock —£very corporation which transfers
any share of stock pursuant to the exercise of an option de-
scribed in section 6039(a)(2), shall identify such stock in a
manner sufficient to enable the accurate reporting of the trans
fer of record titie to such shares. Such identification may be
accomplished by assigning to the certificates of stock issued
pursuant to the exercise of such options a specia! serial num-
ber, or color.

‘Ye US. GOVERNMENT PRINTING OFFICE : 1978—0-263-479


Form 3922
(Rev. Sept. 1978)

Department of the Treasury
Internal Revenue Service

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 A

For Internal
19... Revenue Service

1. Corpo- . 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 1 4. Number of shares to which title is being
transferred
5. Place an “X" in the appropriate box to in-
2. Trans- dicate whether the stock was acquired by
feror option under:
‘a. Employee stock purchase
plabundersection aaa... LI
b. A restricted stock option o
under section 424... . .
b. Identifying number:

‘te US. GOVERNMENT PRINTING OFFICE : 197—-0-263-479




3922 . A For calendar year
(Rev, Sept. 1978) Transfer of Stock Acquired by Certain Options eory BE
Department of the treasury | (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

a. Name and address (including ZIP code) 3. Date stock was transferred to transferor
4. Number of shares to which title is being
transferred
. 5. Place an in the appropriate box to in-
2. Trans: Jieate whether the stock was acquired by
feror option under:
‘a. Employee stock purchase oO
plan under section 423. . . .

B. A restricted stock option o
under section 424 Le

b. Identifying number:

‘Ye US. GOVERNMENT PRINTING OFFICE : 197¢~O-263-479