Form 3921 2010

See IRS Publications 1141 1167 1179 and other IRS resources for information about printing these tax forms. VOID CORRECTED TRANSFEROR S name street address city or town state or province country and ZIP or foreign postal code OMB No. 1545-2129 1 Date option granted Form 3921 2 Date option exercised Rev. August 2013 TRANSFEROR S federal identification number EMPLOYEE S identification number 3 Exercise price per share EMPLOYEE S name 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 Street address including apt. no. City or town state or province country and ZIP or foreign postal code Account number see instructions Form 3921 Rev. August 2013 Cat. No. 41179O www.irs.gov/form3921 Exercise of an Incentive Stock Option Under Section 422 b Copy A For Internal Revenue Service Center File with Form 1096. For Privacy Act and Paperwork Reduction Act Notice see the current version of the General Instructions for Certain Information Returns. To order official IRS forms call 1-800-TAX-FORM 1-800-829-3676 or Order Information Returns and Employer Returns Online and we ll mail you the scannable forms and other products. See IRS Publications 1141 1167 1179 and other IRS resources for information about printing these tax forms. VOID CORRECTED TRANSFEROR S name street address city or town state or province country and ZIP or foreign postal code OMB No. 1545-2129 1 Date option granted Form 3921 2 Date option exercised Rev. August 2013 TRANSFEROR S federal identification number EMPLOYEE S identification number 3 Exercise price per share EMPLOYEE S name 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 Street address including apt. no. City or town state or province country and ZIP or foreign postal code Account number see instructions Form 3921 Rev. August 2013 Cat. No. 41179O www.irs.gov/form3921 Exercise of an Incentive Stock Option Under Section 422 b Copy A For Internal Revenue Service Center File with Form 1096. Attention This form is provided for informational purposes only. Copy A appears in red similar to the official IRS form* Do not file copy A downloaded from this website. The official printed version of this IRS form is scannable but the online version of it printed from this website is not. A penalty may be imposed for filing forms that can t be scanned* See part O in the current General Instructions for Certain Information Returns for more information about penalties. To order official IRS forms call 1-800-TAX-FORM 1-800-829-3676 or Order Information Returns and Employer Returns Online and we ll mail you the scannable forms and other products. See IRS Publications 1141 1167 1179 and other IRS resources for information about printing these tax forms. VOID CORRECTED TRANSFEROR S name street address city or town state or province country and ZIP or foreign postal code OMB No* 1545-2129 1 Date option granted Form 3921 2 Date option exercised Rev* August 2013 TRANSFEROR S federal identification number EMPLOYEE S identification number 3 Exercise price per share EMPLOYEE S name 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 Street address including apt* no* City or town state or province country and ZIP or foreign postal code Account number see instructions Form 3921 Rev* August 2013 Cat* No* 41179O www*irs*gov/form3921 Exercise of an Incentive Stock Option Under Section 422 b Copy A For Internal Revenue Service Center File with Form 1096.