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 IRS.gov/Form1099, for more information about penalties.
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See Publications 1141, 1167, and 1179 for more information about printing these forms.
2525 |
VOID |
CORRECTED |
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TRANSFEROR’S name, street address, city or town, state or province, |
1 Date option granted |
OMB No. 1545-2129 |
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Exercise of an |
country, and ZIP or foreign postal code |
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Form 3921 |
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Incentive Stock |
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Option Under |
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2 Date option exercised |
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(Rev. April 2025) |
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Section 422(b) |
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TRANSFEROR’S TIN |
EMPLOYEE’S TIN |
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3 Exercise price per share |
4 Fair market value per share |
Copy A |
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on exercise date |
For |
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EMPLOYEE’S name |
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$ |
$ |
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Internal Revenue |
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Service Center |
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5 No. of shares transferred |
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For filing information, |
Street address (including apt. no.) |
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6 If other than TRANSFEROR, name, address, and TIN of |
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Privacy Act, and |
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corporation whose stock is being transferred |
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Paperwork Reduction |
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Act Notice, see the |
City or town, state or province, country, and ZIP or foreign postal code |
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General Instructions |
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for Certain |
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Information Returns. |
Account number (see instructions) |
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www.irs.gov/Form1099 |
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Form 3921 (Rev. 4-2025) |
Cat. No. 41179O |
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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