2626 VOID CORRECTED CORPORATION'S name, street address, city or town, state or province, 1 Date option granted OMB No. 1545-2129 Transfer of Stock country, and ZIP or foreign postal code Acquired Through Form 3922 an Employee 2 Date option exercised Stock Purchase Plan Under (Rev. September 2016) Section 423(c) CORPORATION'S federal identification number EMPLOYEE’S identification number 3 Fair market value per share 4 Fair market value per share Copy A on grant date on exercise date For EMPLOYEE’S name $ $ Internal Revenue 5 Exercise price paid per share 6 No. of shares transferred Service Center $ File with Form 1096. Street address (including apt. no.) 7 Date legal title transferred For Privacy Act and Paperwork Reduction City or town, state or province, country, and ZIP or foreign postal code Act Notice, see the current version of the 8 Exercise price per share determined as if the option was General Instructions for Account number (see instructions) exercised on the date shown in box 1 Certain Information Returns. $ Form 3922 (Rev. 9-2016) Cat. No. 41180P www.irs.gov/form3922 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 CORPORATION'S name, street address, city or town, state or province, 1 Date option granted OMB No. 1545-2129 Transfer of Stock country, and ZIP or foreign postal code Acquired Through Form 3922 an Employee 2 Date option exercised Stock Purchase Plan Under (Rev. September 2016) Section 423(c) CORPORATION'S federal identification number EMPLOYEE’S identification number 3 Fair market value per share 4 Fair market value per share Copy B on grant date on exercise date For Employee EMPLOYEE’S name $ $ 5 Exercise price paid per share 6 No. of shares transferred This is important tax $ information and is Street address (including apt. no.) 7 Date legal title transferred being furnished to the Internal Revenue Service. City or town, state or province, country, and ZIP or foreign postal code 8 Exercise price per share determined as if the option was Account number (see instructions) exercised on the date shown in box 1 $ Form 3922 (Rev. 9-2016) (keep for your records) www.irs.gov/form3922 Department of the Treasury - Internal Revenue Service |
Instructions for Employee You have received this form because (1) your employer (or its Box 3. Shows the fair market value (FMV) per share on the transfer agent) has recorded a first transfer of legal title of date the option to purchase the stock was granted to you. stock you acquired pursuant to your exercise of an option Box 4. Shows the FMV per share on the date you exercised granted under an employee stock purchase plan, and (2) the the option to purchase the stock. exercise price was less than 100% of the value of the stock on the date shown in box 1 or was not fixed or determinable on Box 5. Shows the price paid per share on the date you that date. exercised the option to purchase the stock. No income is recognized when you exercise an option Box 6. Shows the number of shares to which legal title was under an employee stock purchase plan. However, you must transferred by you. recognize (report) gain or loss on your tax return for the year in Box 7. Shows the date legal title of the shares was first which you sell or otherwise dispose of the stock. Keep this transferred by you. form and use it to figure the gain or loss. For more information, Box 8. If the exercise price per share was not fixed or see Pub. 525. determinable on the date entered in box 1, box 8 shows the Account number. May show an account or other unique exercise price per share determined as if the option was number your employer or transfer agent assigned to exercised on the date in box 1. If the exercise price per share distinguish your account. was fixed or determinable on the date shown in box 1, then Box 1. Shows the date the option to purchase the stock was box 8 will be blank. granted to you. Future developments. For the latest information about Box 2. Shows the date you exercised the option to purchase developments related to Form 3922 and its instructions, such the stock. as legislation enacted after they were published, go to www.irs.gov/form3922. |
VOID CORRECTED CORPORATION'S name, street address, city or town, state or province, 1 Date option granted OMB No. 1545-2129 Transfer of Stock country, and ZIP or foreign postal code Acquired Through Form 3922 an Employee 2 Date option exercised Stock Purchase Plan Under (Rev. September 2016) Section 423(c) CORPORATION'S federal identification number EMPLOYEE’S identification number 3 Fair market value per share 4 Fair market value per share Copy C on grant date on exercise date For Corporation EMPLOYEE’S name $ $ This copy should be 5 Exercise price paid per share 6 No. of shares transferred retained by the corporation. $ Street address (including apt. no.) 7 Date legal title transferred For Privacy Act and Paperwork Reduction City or town, state or province, country, and ZIP or foreign postal code Act Notice, see the current version of the 8 Exercise price per share determined as if the option was General Instructions Account number (see instructions) exercised on the date shown in box 1 for Certain Information Returns. $ Form 3922 (Rev. 9-2016) www.irs.gov/form3922 Department of the Treasury - Internal Revenue Service |
Instructions for Corporation To complete Form 3922, use: File Copy A of this form with the IRS by February 28 of the year following the year of first transfer of the • The current General Instructions for Certain stock acquired through the employee stock purchase Information Returns, and plan. If you file electronically, the due date is March 31 • The current Instructions for Forms 3921 and 3922. of the year following the year of first transfer of the stock acquired through the employee stock purchase To get or to order these instructions, go to plan. To file electronically, you must have software that www.irs.gov/form3922. generates a file according to the specifications in Pub. Due dates. Furnish Copy B of this form to the employee 1220. by January 31 of the year following the year of first Need help? If you have questions about reporting on transfer of the stock acquired through the employee Form 3922, call the information reporting customer stock purchase plan. service site toll free at 1-866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free). |