Form 3921

(Rev. Dec. 1978)

Department of the Treasury
Internal Revenue Service

Exercise of a Qualified or Restricted Stock Option
(U.S. information return under section 6039(a)(1) of the Internal Revenue Code)

For calendar year Copy C

For Transferor
19. Stock

1

Corpo-
ration
Trans-
ferring
Stock

a. Name and address (including ZIP code)

2. Name of corporation whose stock is transferred

(lf different from corporation transferring stock)

b.

Employer identification number

. Person

‘to Whom
Stock
is Trans-
ferred

r

Name and address (including ZIP code)

4. Type of option exercised (Check one)
[ZA aualified stock option under section 422(b)

[1 A restricted stock option under section 424(b)

5. Date option granted | 6. Date of transfer

7. Total fair market value of all shares of stock
at time option exercised

‘8. Option price (Total cost of all shares)

$

‘9. Total tax preference items (Line 7 less line 8)

$

b. Identifying number >

10. No. of shares transferred p>

‘Yr US. GOVERNMENT PRINTING OFFICE : 1978-O-263-238

E1No,04-2502514


Note: With certain exceptions specified in section 422(c)(7),
stock options granted after May 20, 1976, will no longer quality
as qualified stock options under section 422. Furthermore,
those options specified in section 422(c)(7) must be exercised
before May 21, 1981, in order to retain their qualified status.

Restricted stock options granted after December 31, 1963,
which comply with section 424(c)(3) must be exercised before
May 21, 1981, in order to retain their status as restricted stock
options under section 424.

This form is a copy of the information return filed with the
Internal Revenue Service by the corporation which transferred
shares of stock to you. The exercise of your option to buy the
stock generally does not affect your income tax liability at the
time of purchase. The exception to this general rule occurs

‘Ye US, GOVERNMENT PRINTING OFFICE : 1978—O-263-238 et

under a Qualified Stock Option plan when the price of the stock
is less than the fair market value at the time the option is
granted. Contact your nearest Internal Revenue Service office
for further information regarding the tax effect when the above
exception occurs or for information regarding the tax treatment
of any gain on disposition of the stock.

Minimum Tax.—With respect to the transfer of stock pur-
Suant to the exercise of a qualified or restricted stock option,
the excess of the fair market value of the stock at the time of
exercise (line 7) over the option price (line 8) is a tax preference
item (section 57(a)(6)). This tax preference item should be
combined with other items of tax preference to determine if the
minimum tax applies. See Form 4625, Computation of Minimum
Tax,

No. 04-2502514


Instructions

Note: With certain exceptions specified in section 422(c)(7),
stock options granted after May 20, 1976, will no longer qualify as
qualified stock options under section 422. Furthermore, those
options specified in section 422(c)(7) must be exercised before
May 21, 1981, in order to retain their qualified status.

Restricted stock options granted after December 31, 1963,
which comply with section 424(c)(3) must be exercised before
May 21, 1981, in order to retain their status as restricted stock
options under section 424,

Who Must File.—Every corporation which transfers a share of
stock to any person pursuant to such person's exercise of a quali-
fied stock option described in section 422(b), or a restricted stock
option described in section 424(b), must file this return.

Where To File.—See the instructions for your income tax return
for a listing of the Service Centers where Form 3921 can be filed.

When To File.—This return must be filed for the calendar year
on or before February 28 of the following year.

3 US, GOVERNMENT PRINTING OFFICE : 1978—-0-263-238 e1

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. 7

A statement shall be considered to be furnished to a person if
it is mailed to the person’s last known address.

Extension of Time for Furnishing Statement.—yYour 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 a copy of this return to each person whose
name and identifying number is shown on such return. The
application must contain a full recital of the reasons for request-
ing 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 application must be filed on or before January 31
of the year following the calendar year for which the form is filed.

No.04-2502514


fer Bee Exercise of a Qualified or Restricted Stock Option | “““"TM*""" | Copy A

Department of the Treasury | (U.S, information return under section 6039(a)(1) of the Internal Revenue Code) 19 peror internal

a. Name and address (including ZIP code) 2. Name of corporation whose stock is transferred
1. Corpo- (If different from corporation transferring stock)
ration
Trans-
ferring
Stock ~ ———
b. Employer identification number > 4, Type of option exercised (Check one)
a. Name and address (including ZIP code) [Dy A qualified stock option under section 422(b)
[LJ A restricted stock option under section 424(b)
5 5. Date option granted | 6. Date of transfer
3. Person r
to Whom 7. Total fair market value of all shares of stock
Stock at time option exercised
is Trans-
ferred 8. Option price (Total cost of all shares)
$
‘9. Total tax preference items (Line 7 less line 8)
$
b. Identifying number >> 10. No. of shares transferred >

‘$y USS. GOVERNMENT PRINTING OFFICE : 197¢—O~263-238 E1No, 04-2502514




Form 3921
(Rev. Dec. 1978)

Department of the Treasury
Internal Revenue Service

Exercise of a Qualified or Restricted Stock Option
(U.S. information return under section 6039(a)(1) of the Internal Revenue Code)

For calendar year Copy B

For Person
19... Exercising Option

1. Corpo-
ration
Trans-
ferring
Stock

a. Name and address (including ZIP code)

2. Name of corporation whose stock is transferred

(If different from corporation transferring stock)

b. Employer identification number >»

3. Person
‘to Whom
Stock
is Trans-
ferred

a. Name and address (including ZIP code)

Tc 7

4. Type of option exercised (Check one)
[1] A aualified stock option under section 422(b)

1 A restricted stock option under section 424(b)

5. Date option granted | 6. Date of transfer

7. Total fair market value of all shares of stock
time option exercised

$

8. Option price (Total cost of all shares)
$

‘9. Total tax preference items (Line 7 less line 8)
$

b. Identifying number >

10. No. of shares transferred p>

‘Ye US, GOVERNMENT PRINTING OFFICE : 1978—-O-263-238

EI No, 04-2502514