Attention: 

Copy A of this form is provided for informational purposes only. Copy A appears in red, 
similar to the official IRS form. The official printed version of Copy A of this IRS form is 
scannable, but the online version of it, printed from this website, is not. Do not print and file 
copy A downloaded from this website; a penalty may be imposed for filing with the IRS 
information return forms that can’t be scanned. See part O in the current General 
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more 
information about penalties.

Please note that Copy B and other copies of this form, which appear in black, may be 
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Information returns may also be filed electronically using the IRS Filing Information Returns 
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See IRS Publications 1141, 1167, and 1179 for more information about printing these tax 
forms.

              2525                      VOID            CORRECTED
TRANSFEROR’S name, street address, city or town, state or province,      1 Date option granted         OMB No. 1545-2129
country, and ZIP or foreign postal code                                                                                            Exercise of an 
                                                                                                     Form 3921                     Incentive Stock 
                                                                         2 Date option exercised                                   Option Under 
                                                                                                                                   Section 422(b)
                                                                                                     (Rev. October 2017)
TRANSFEROR’S TIN                    EMPLOYEE’S TIN                       3 Exercise price per share  4 Fair market value per share Copy A
                                                                                                       on exercise date
                                                                                                                                   For 
EMPLOYEE’S name                                                          $                           $                             Internal Revenue 
                                                                         5 No. of shares transferred                               Service Center
                                                                                                                                   File with Form 1096.
Street address (including apt. no.)                                      6 If other than TRANSFEROR, name, address, and TIN of     For Privacy Act and 
                                                                           corporation whose stock is being transferred            Paperwork 
                                                                                                                                   Reduction Act 
City or town, state or province, country, and ZIP or foreign postal code                                                           Notice, see the 
                                                                                                                                   current version of 
                                                                                                                                   the General 
Account number (see instructions)                                                                                                  Instructions for 
                                                                                                                                   Certain Information 
                                                                                                                                   Returns.
Form 3921 (Rev. October 2017)           Cat. No. 41179O                  www.irs.gov/Form3921          Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

                                                   CORRECTED (if checked)
TRANSFEROR’S name, street address, city or town, state or province,      1 Date option granted         OMB No. 1545-2129
country, and ZIP or foreign postal code                                                                                            Exercise of an 
                                                                                                     Form 3921                     Incentive Stock 
                                                                         2 Date option exercised                                   Option Under 
                                                                                                                                   Section 422(b)
                                                                                                     (Rev. October 2017)
TRANSFEROR’S TIN                    EMPLOYEE’S TIN                       3 Exercise price per share  4 Fair market value per share Copy B
                                                                                                       on exercise date            For Employee
EMPLOYEE’S name                                                          $                           $                             This is important tax 
                                                                         5 No. of shares transferred                               information and is 
                                                                                                                                   being furnished to the 
                                                                                                                                   IRS. If you are required 
Street address (including apt. no.)                                      6 If other than TRANSFEROR, name, address, and TIN of     to file a return, a 
                                                                           corporation whose stock is being transferred            negligence penalty or 
                                                                                                                                   other sanction may be 
City or town, state or province, country, and ZIP or foreign postal code                                                           imposed on you if this 
                                                                                                                                   item is required to be 
                                                                                                                                   reported and the IRS 
Account number (see instructions)                                                                                                  determines that it has 
                                                                                                                                   not been reported. 
Form 3921 (Rev. October 2017)           (keep for your records)          www.irs.gov/Form3921          Department of the Treasury - Internal Revenue Service

Instructions for Employee                                            Box 1. Shows the date the option to purchase the stock was 
                                                                     granted to you.
You have received this form because your employer (or transfer 
agent) transferred your employer’s stock to you pursuant to your     Box 2. Shows the date you exercised the option to purchase the 
exercise of an incentive stock option (ISO). You must recognize      stock.
(report) gain or loss on your tax return for the year in which you   Box 3. Shows the exercise price per share of stock.
sell or otherwise dispose of the stock. Keep this form and use it to Box 4. Shows the fair market value (FMV) of a share of stock on 
figure the gain or loss. For more information, see Pub. 525,         the date the option was exercised.
Taxable and Nontaxable Income.
When you exercise an ISO, you may have to include in                 Box 5. Shows the number of shares of stock transferred to you 
                                                                     pursuant to the exercise of the option.
alternative minimum taxable income a portion of the fair market                                    
value of the stock acquired through the exercise of the option. For  Box 6. Shows the name, address, and TIN of the corporation 
more information, see Form 6251, Alternative Minimum                 whose stock is being transferred (if other than the corporation 
Tax—Individuals, and its instructions.                               shown in TRANSFEROR boxes in the upper left corner of the 
                                                                     form).
Employee’s taxpayer identification number (TIN). For your 
protection, this form may show only the last four digits of your     Future developments. For the latest information about 
social security number (SSN), individual taxpayer identification     developments related to Form 3921 and its instructions, such as 
number (ITIN), or adoption taxpayer identification number (ATIN).    legislation enacted after they were published, go to    
However, the employer has reported your complete TIN to the          www.irs.gov/Form3921.
IRS.
Account number. May show an account or other unique number 
your employer or transfer agent assigned to distinguish your 
account.

                                                   CORRECTED (if checked)
TRANSFEROR’S name, street address, city or town, state or province,      1 Date option granted        OMB No. 1545-2129
country, and ZIP or foreign postal code                                                                                           Exercise of an 
                                                                                                    Form 3921                     Incentive Stock 
                                                                         2 Date option exercised                                  Option Under 
                                                                                                                                  Section 422(b)
                                                                                                    (Rev. October 2017)
TRANSFEROR’S TIN                    EMPLOYEE’S TIN                       3 Exercise price per share 4 Fair market value per share 
                                                                                                      on exercise date
                                                                                                                                  Copy C
EMPLOYEE’S name                                                          $                          $                             For Corporation
                                                                         5 No. of shares transferred
                                                                                                                                  This copy should 
Street address (including apt. no.)                                      6 If other than TRANSFEROR, name, address, and TIN of    be retained by the 
                                                                           corporation whose stock is being transferred           corporation whose 
                                                                                                                                  stock has been 
City or town, state or province, country, and ZIP or foreign postal code                                                          transferred under 
                                                                                                                                  Section 422(b). 
Account number (see instructions)

Form 3921 (Rev. October 2017)           (keep for your records)          www.irs.gov/Form3921         Department of the Treasury - Internal Revenue Service

                                        VOID       CORRECTED 
TRANSFEROR’S name, street address, city or town, state or province,      1 Date option granted         OMB No. 1545-2129
country, and ZIP or foreign postal code                                                                                            Exercise of an 
                                                                                                      Form 3921                    Incentive Stock 
                                                                         2 Date option exercised                                   Option Under 
                                                                                                                                   Section 422(b)
                                                                                                      (Rev. October 2017)
TRANSFEROR’S TIN                    EMPLOYEE’S TIN                       3 Exercise price per share  4 Fair market value per share Copy D
                                                                                                       on exercise date            For Transferor
EMPLOYEE’S name                                                          $                           $
                                                                         5 No. of shares transferred                               For Privacy Act and 
                                                                                                                                   Paperwork 
                                                                                                                                   Reduction Act 
Street address (including apt. no.)                                      6 If other than TRANSFEROR, name, address, and TIN of     Notice, see the 
                                                                           corporation whose stock is being transferred            current version of 
City or town, state or province, country, and ZIP or foreign postal code                                                           the General 
                                                                                                                                   Instructions for 
                                                                                                                                   Certain Information 
Account number (see instructions)                                                                                                  Returns.

Form 3921 (Rev. October 2017)                www.irs.gov/Form3921                                      Department of the Treasury - Internal Revenue Service

Instructions for Transferor                              Furnish Copy C of this form to the corporation whose 
                                                         stock is being transferred by January 31 of the year 
To complete Form 3921, use:                              following the year of exercise of the ISO.
• the current General Instructions for Certain           File Copy A of this form with the IRS by February 28 
Information Returns, and                                 of the year following the year of exercise of the ISO. If 
• the current Instructions for Forms 3921 and 3922.      you file electronically, the due date is March 31 of the 
To order these instructions and additional forms, go     year following the year of exercise of the ISO. To file 
to www.irs.gov/Form3921.                                 electronically, you must have software that generates a 
                                                         file according to the specifications in Pub. 1220. The 
Caution: Because paper forms are scanned during          IRS does not provide a fill-in form option for Copy A.
processing, you cannot file Forms 1096, 1097, 1098, 
1099, 3921, 3922, or 5498 that you print from the IRS    Need help? If you have questions about reporting on 
website.                                                 Form 3921, call the information reporting customer 
                                                         service site toll free at 866-455-7438 or 304-263-8700 
Due dates. Furnish Copy B of this form to the employee   (not toll free). Persons with a hearing or speech 
by January 31 of the year following the year of exercise disability with access to TTY/TDD equipment can call 
of the ISO.                                              304-579-4827 (not toll free).