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Page 2 of 2 Fileid: … 921&3922/201710/A/XML/Cycle04/source 13:45 - 3-Oct-2017
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
Box 6. If Other Than TRANSFEROR, Name, Statements to Transferors
Address, and TIN of Corporation Whose Stock If you are required to file Form 3922, you must furnish a
Is Being Transferred statement to the transferor. For more information, see part M
Enter the name, address, and TIN of the corporation whose in the current version of the General Instructions for Certain
stock is being transferred pursuant to the exercise of the Information Returns.
option. Enter this information only if the corporation is not the Truncating recipient’s TIN on payee statements.
entity shown in the TRANSFEROR boxes in the upper left Pursuant to Treasury Regulations section 301.6109-4, all
corner of Form 3921. filers of this form may truncate a recipient’s TIN (social
security number (SSN), individual taxpayer identification
number (ITIN), adoption taxpayer identification number
Specific Instructions for Form 3922
(ATIN), or employer identification number (EIN) on payee
statements. Truncation is not allowed on any documents the
Who Must File
filer files with the IRS. A payer’s TIN may not be truncated on
Every corporation, which in any calendar year records, or has any form. See part J in the current version of the General
by its agent recorded, a transfer of the legal title of a share of Instructions for Certain Information Returns.
stock acquired by the transferor (person who acquires the
shares pursuant to the exercise of the option) pursuant to the Employee's Name, Address, and TIN
transferor's exercise of an option granted under an employee Enter the name, address, and TIN of the transferor.
stock purchase plan and described in section 423(c) (where
the exercise price is less than 100% of the value of the stock Account Number
on the date of grant, or is not fixed or determinable on the
date of grant), must, for that calendar year, file Form 3922 for The account number is required if you have multiple
each transfer made during that year. accounts for a transferor for whom you are filing more than
one Form 3922. Additionally, the IRS encourages you to
A return is required by reason of a transfer described in designate an account number for all Forms 3922 that you file.
section 6039(a)(2) only for the first transfer of legal title of the See part L in the current version of the General Instructions
shares by the transferor, including the first transfer of legal for Certain Information Returns.
title to a recognized broker or financial institution. If a
contractual agreement exists or is entered into with a Box 1. Date Option Granted
recognized broker or financial institution pursuant to which Enter the date the option was granted.
shares acquired upon exercise of the option will be
immediately deposited into a brokerage account established Box 2. Date Option Exercised
on behalf of the transferor, then the deposit of shares by the Enter the date the option was exercised.
transferor into the brokerage account following the exercise
of the option is the first transfer of legal title of the shares Box 3. Fair Market Value Per Share on Grant
acquired by the transferor, and the corporation is only Date
required to file a return relating to that transfer of legal title.
Enter the fair market value (FMV) per share of stock on the
Shares of stock transferred as a result of the exercise of date the option was granted.
an option described above must be identified in a manner
sufficient to enable the accurate reporting of the transfer of Box 4. Fair Market Value Per Share on Exercise
legal title to such shares. This identification can be made by Date
assigning to the share certificates of stock issued pursuant to
Enter the FMV per share of stock on the date the option to
such options a special serial number or color.
purchase the stock was exercised.
The corporation whose stock is being transferred must file
Form 3922. Box 5. Exercise Price Paid Per Share
Exception. A Form 3922 is not required for the first transfer Enter the price paid per share on the date the option was
of legal title of a share of stock by an employee who is a exercised.
nonresident alien (as defined in section 7701(b)) and to
Box 6. Number of Shares Transferred
whom the corporation is not required to provide a Form W-2,
Wage and Tax Statement, for any calendar year within the Enter the number of shares to which legal title was
time period beginning with the first day of the calendar year in transferred.
which the option was granted to the employee and ending on
the last day of the calendar year in which the employee first Box 7. Date Legal Title Transferred
transferred legal title to shares acquired under the option. For Enter the date legal title of the shares was first transferred.
this purpose, the term “corporation” is defined in section
7701(a) and includes, but is not limited to: Box 8. Exercise Price Per Share Determined as
The corporation issuing the stock, if the Option Was Exercised on the Date Shown
A related corporation of the corporation, in Box 1
Any agent of the corporation,
If the exercise price per share was not fixed or determinable
Any party distributing shares of stock or other payments in
on the date of grant entered in box 1, enter the exercise price
connection with the plan (for example, a brokerage firm), and
per share determined as if the option was exercised on the
Any party in control of the payment of remuneration for
date of grant entered in box 1. If the exercise price per share
employment to the employee.
is fixed or determinable on the date of grant entered in box 1,
then leave box 8 blank.
-2- Instrs for Forms 3921 and 3922 (Rev. Oct. 2017)
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