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