scannable forms and other products. 

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

about printing these tax forms. 
CORRECTED

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

2 Date option exercised

CORPORATION’S federal identification number EMPLOYEE’S identification number Fair market value per share

on exercise date

Fair market value per share 4

on grant date

3

6 No. of shares transferred

EMPLOYEE’S name

Street address (including apt. no.) 7 Date legal title transferred

City, state, and ZIP code

Account number (see instructions)

Form 3922 (Rev. October 2010) Department of the Treasury - Internal Revenue Service

2626 VOID

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

Cat. No. 41180P

Form 3922

Transfer of Stock

Acquired Through

an Employee

Stock Purchase

Plan Under

Section 423(c)

5

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

Exercise price paid per share

$

(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.

Exercise price per share determined as if the option was

exercised on the date shown in box 1.

8

$
Copy B

This is important tax

information and is

being furnished to

the Internal Revenue

Service.

For Employee

Transfer of Stock

Acquired Through

an Employee

Stock Purchase

Plan Under

Section 423(c)

CORRECTED

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

2 Date option exercised

CORPORATION’S federal identification number EMPLOYEE’S identification number Fair market value per share

on exercise date

Fair market value per share 4

on grant date

3

6 No. of shares transferred

EMPLOYEE’S name

Street address (including apt. no.) 7 Date legal title transferred

City, state, and ZIP code

Account number (see instructions)

Form 3922 (Rev. October 2010) (keep for your records) Department of the Treasury - Internal Revenue Service

Form 3922

5 Exercise price paid per share

$

(Rev. October 2010)

Date option granted

$

$

Exercise price per share determined as if the option was

exercised on the date shown in box 1.

8

$
Instructions for Employee

You have received this form because (1) your employer

(or its transfer agent) has recorded a first transfer of

legal title of stock you acquired pursuant to your

exercise of an option granted under an employee stock

purchase plan and (2) the exercise price was less than

100 percent of the value of the stock on the date

shown in box 1 or was not fixed or determinable on

that date.

Account number. May show an account or other

unique number your employer or transfer agent

assigned to distinguish your account.

Box 4. Shows the FMV per share on the date you

exercised the option to purchase the stock.

Box 5. Shows the price paid per share on the date you

exercised the option to purchase the stock.

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 7. Shows the date legal title of the shares was

first transferred by you.

Box 3. Shows the fair market value (FMV) per share on

the date the option to purchase the stock was granted

to you.

Box 6. Shows the number of shares to which legal title

was transferred by you.

No income is recognized when you exercise an

option under an employee stock purchase plan.

However, 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. Box 8. If the exercise price per share was not fixed or

determinable on the date entered in box 1, box 8

shows the exercise price per share determined as if

the option was exercised on the date in box 1. If the

exercise price per share was fixed or determinable on

the date shown in box 1, then box 8 will be blank.
Copy C

For Corporation

This copy should

be retained by the

corporation.

CORRECTED

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

2 Date option exercised

CORPORATION’S federal identification number EMPLOYEE’S identification number Fair market value per share

on exercise date

Fair market value per share 4

on grant date

3

6 No. of shares transferred

EMPLOYEE’S name

Street address (including apt. no.) 7 Date legal title transferred

City, state, and ZIP code

Account number (see instructions)

Form 3922 (Rev. October 2010)

VOID

Form 3922

Transfer of Stock

Acquired Through

an Employee

Stock Purchase

Plan Under

Section 423(c)

5 Exercise price paid per share

$

(Rev. October 2010)

Date option granted

$

$

Exercise price per share determined as if the option was

exercised on the date shown in box 1.

8

$

Department of the Treasury - Internal Revenue Service

For Privacy Act and

Paperwork

Reduction Act

Notice, see the

most current

version of the

General

Instructions for

Certain Information

Returns.
Instructions for Corporation

General and specific form instructions are provided as

separate products. The products you should use to

complete Form 3922 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 first transfer of the stock acquired through the

employee stock purchase plan.

File Copy A of this form with the IRS by February 28

of the year following the year of first transfer of the

stock acquired through the employee stock purchase

plan. If you file electronically, the due date is March 31

of the year following the year of first transfer of the

stock acquired through the employee stock purchase

plan. 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

Caution: Because paper forms are scanned during does not provide a fill-in form option.

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 3922, 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.