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              2525                         VOID            CORRECTED
TRANSFEROR'S name, street address, city or town, state or province, country, and 1 Date option granted         OMB No. 1545-2129
ZIP or foreign postal code                                                                                                                 Exercise of an 
                                                                                                             Form 3921                     Incentive Stock 
                                                                                 2 Date option exercised                                   Option Under 
                                                                                                                                           Section 422(b)
                                                                                                             (Rev. August 2013)
TRANSFEROR'S federal identification number EMPLOYEE’S identification number      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 EIN 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. August 2013)               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, country, and 1 Date option granted         OMB No. 1545-2129
ZIP or foreign postal code                                                                                                                 Exercise of an 
                                                                                                             Form 3921                     Incentive Stock 
                                                                                 2 Date option exercised                                   Option Under 
                                                                                                                                           Section 422(b)
                                                                                                             (Rev. August 2013)
TRANSFEROR'S federal identification number EMPLOYEE’S identification number      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 
                                                                                   No. of shares transferred                               information and is 
                                                                                 5                                                         being furnished to the 
                                                                                                                                           Internal Revenue 
Street address (including apt. no.)                                              6 If other than TRANSFEROR, name, address, and EIN of     Service. If you are 
                                                                                                                                           required to file a return, 
                                                                                   corporation whose stock is being transferred            a negligence penalty or 
City or town, state or province, country, and ZIP or foreign postal code                                                                   other sanction may be 
                                                                                                                                           imposed on you if this 
                                                                                                                                           item is required to be 
Account number (see instructions)                                                                                                          reported and the IRS 
                                                                                                                                           determines that it has 
                                                                                                                                           not been reported. 
Form 3921 (Rev. August 2013)               (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  Box 2. Shows the date you exercised the option to 
pursuant to your exercise of an incentive stock option    purchase the stock.
(ISO). You must recognize (report) gain or loss on your   Box 3. Shows the exercise price per share of stock.
tax return for the year in which you sell or otherwise 
dispose of the stock. Keep this form and use it to figure Box 4. Shows the fair market value (FMV) of a share of 
                                                          stock on the date the option was exercised.
the gain or loss. For more information, see Pub. 525, 
Taxable and Nontaxable Income.                            Box 5. Shows the number of shares of stock transferred 
                                                          to you pursuant to the exercise of the option.
When you exercise an ISO, you may have to include                                              
in alternative minimum taxable income a portion of the    Box 6. Shows the name, address, and employer 
fair market value of the stock acquired through the       identification number (EIN) of the corporation whose 
exercise of the option. For more information, see Form    stock is being transferred (if other than the corporation 
6251, Alternative Minimum Tax—Individuals, and its        shown in TRANSFEROR boxes in the upper left corner 
instructions.                                             of the form).
Account number. May show an account or other              Future developments. For the latest information about 
unique number your employer or transfer agent             developments related to Form 3921 and its instructions, 
assigned to distinguish your account.                     such as legislation enacted after they were published, 
                                                          go to www.irs.gov/form3921.

                                           CORRECTED (if checked)
TRANSFEROR'S name, street address, city or town, state or province, country, and 1 Date option granted        OMB No. 1545-2129
ZIP or foreign postal code                                                                                                                Exercise of an 
                                                                                                             Form 3921                    Incentive Stock 
                                                                                 2 Date option exercised                                  Option Under 
                                                                                                                                          Section 422(b)
                                                                                                             (Rev. August 2013)
TRANSFEROR'S federal identification number EMPLOYEE’S identification number      3 Exercise price per share 4 Fair market value per share Copy C
                                                                                                              on exercise date            For Corporation
EMPLOYEE’S name                                                                  $                          $
                                                                                 5 No. of shares transferred
                                                                                                                                          This copy should 
Street address (including apt. no.)                                              6 If other than TRANSFEROR, name, address, and EIN 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. August 2013)               (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, country, and 1 Date option granted         OMB No. 1545-2129
ZIP or foreign postal code                                                                                                                 Exercise of an 
                                                                                                              Form 3921                    Incentive Stock 
                                                                                 2 Date option exercised                                   Option Under 
                                                                                                                                           Section 422(b)
                                                                                                              (Rev. August 2013)
TRANSFEROR'S federal identification number EMPLOYEE’S identification number      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 EIN 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. August 2013)                    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 or call 1-800-TAX-FORM           electronically, you must have software that generates a 
(1-800-829-3676).                                        file according to the specifications in Pub. 1220, 
                                                         Specifications for Electronic Filing of Forms 1097, 1098, 
Caution. Because paper forms are scanned during          1099, 3921, 3922, 5498, 8935, and W-2G. The IRS does 
processing, you cannot file Forms 1096, 1097, 1098,      not provide a fill-in form option.
1099, 3921, 3922, or 5498 that you print from the IRS 
website.                                                 Need help? If you have questions about reporting on 
                                                         Form 3921, call the information reporting customer 
Due dates. Furnish Copy B of this form to the employee   service site toll free at 1-866-455-7438 or 304-263-8700 
by January 31 of the year following the year of exercise (not toll free). Persons with a hearing or speech 
of the ISO.                                              disability with access to TTY/TDD equipment can call 
                                                         304-579-4827 (not toll free).