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Page 2 of 2 Fileid: … 921&3922/201308/A/XML/Cycle05/source 8:44 - 24-Jul-2013
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
Statements to Transferors
Specific Instructions for Form 3922 If you are required to file Form 3922, you must furnish a
statement to the transferor. For more information, see part
Who Must File M in the current version of the General Instructions for
Every corporation, which in any calendar year records, or Certain Information Returns.
has by its agent recorded, a transfer of the legal title of a
share of stock acquired by the transferor (person who Employee's Name, Address, and Identification
acquires the shares pursuant to the exercise of the option) Number
pursuant to the transferor's exercise of an option granted Enter the name, address, and identifying number of the
under an employee stock purchase plan and described in transferor.
section 423(c) (where the exercise price is less than
100% of the value of the stock on the date of grant, or is Account Number
not fixed or determinable on the date of grant), must, for The account number is required if you have multiple
that calendar year, file Form 3922 for each transfer made accounts for a transferor for whom you are filing more
during that year. than one Form 3922. Additionally, the IRS encourages
A return is required by reason of a transfer described in you to designate an account number for all Forms 3922
section 6039(a)(2) only for the first transfer of legal title of that you file. See part L in the current version of the
the shares by the transferor, including the first transfer of General Instructions for Certain Information Returns.
legal 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 Box 2. Date Option Exercised
established on behalf of the transferor, then the deposit of Enter the date the option was exercised.
shares by the transferor into the brokerage account
following the exercise of the option is the first transfer of Box 3. Fair Market Value Per Share on Grant
legal title of the shares acquired by the transferor, and the Date
corporation is only required to file a return relating to that
Enter the fair market value (FMV) per share of stock on
transfer of legal title.
the date the option was granted.
Shares of stock transferred as a result of the exercise
of an option described above must be identified in a Box 4. Fair Market Value Per Share on Exercise
manner sufficient to enable the accurate reporting of the Date
transfer of legal title to such shares. This identification can Enter the FMV per share of stock on the date the option to
be made by assigning to the share certificates of stock purchase the stock was exercised.
issued pursuant to such options a special serial number or
color. Box 5. Exercise Price Paid Per Share
The corporation whose stock is being transferred must Enter the price paid per share on the date the option was
file Form 3922. exercised.
Exception. A Form 3922 is not required for the first
transfer of legal title of a share of stock by an employee Box 6. Number of Shares Transferred
who is a nonresident alien (as defined in section 7701(b)) Enter the number of shares to which legal title was
and to whom the corporation is not required to provide a transferred.
Form W-2, Wage and Tax Statement, for any calendar
year within the time period beginning with the first day of Box 7. Date Legal Title Transferred
the calendar year in which the option was granted to the Enter the date legal title of the shares was first transferred.
employee and ending on the last day of the calendar year
in which the employee first transferred legal title to shares Box 8. Exercise Price Per Share Determined as
acquired under the option. For this purpose, the term if the Option Was Exercised on the Date Shown
“corporation” is defined in section 7701(a) and includes, in Box 1
but is not limited to: If the exercise price per share was not fixed or
The corporation issuing the stock, determinable on the date of grant entered in box 1, enter
A related corporation of the corporation, the exercise price per share determined as if the option
Any agent of the corporation, was exercised on the date of grant entered in box 1. If the
Any party distributing shares of stock or other payments exercise price per share is fixed or determinable on the
in connection with the plan (for example, a brokerage date of grant entered in box 1, then leave box 8 blank.
firm), and
Any party in control of the payment of remuneration for
employment to the employee.
-2- Instrs for Forms 3921 and 3922 (Rev. Aug. 2013)
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