0425 Form 3921 (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f3921.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

Exercise of an

Option Under Section 422(b)

Copy A

For Internal Revenue

Service Center

For filing information,

Privacy Act, and Paperwork Reduction

Act Notice, see the General Instructions

for Certain Information Returns .

www.irs.gov/Form1099

2525 VOID CORREC		CTED
TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	1 Date option granted	Form 3921 (Rev. April 2025) OMB No. 1545-2129
TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	2 Date option exercised	2 Date option exercised
TRANSFEROR’S TIN	EMPLOYEE’S TIN	3 Exercise price per share $	4 Fair market value per share on exercise date $
EMPLOYEE’S name	EMPLOYEE’S name	EMPLOYEE’S name	EMPLOYEE’S name
EMPLOYEE’S name	EMPLOYEE’S name	5 No. of shares transferred
Street address (including apt. no.)	Street address (including apt. no.)	6 If other than TRANSFEROR, name, address, and TIN of corporation whose stock is being transferred	6 If other than TRANSFEROR, name, address, and TIN of corporation whose stock is being transferred
City or town,state or province, country, and ZIP or foreign postal code
Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Cat. No. 41179O

Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)

Exercise of an

Option Under Section 422(b)

Copy B For Employee

This is important tax

not been reported.

information and is being furnished to the IRS. If you are required

to file a return, a negligence penalty or other sanction may be

imposed on you if this

item is required to be

reported and the IRS determines that it has

TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code		1 Date option granted	OMB No. 1545-2129 Form 3921 (Rev. April 2025)
TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	2 Date option exercised	2 Date option exercised
TRANSFEROR’S TIN	EMPLOYEE’S TIN	3 Exercise price per share $	4 Fair market value per share on exercise date $
EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code
EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	5 No. of shares transferred
EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	6 If other than TRANSFEROR, name, address, and TIN of corporation whose stock is being transferred	6 If other than TRANSFEROR, name, address, and TIN of corporation whose stock is being transferred
Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)

Department of the Treasury - Internal Revenue Service

Instructions for Employee

You have received this form because your employer (or transfer agent) transferred your employer’s stock to you pursuant to your exercise of an incentive stock option (ISO). 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, Taxable and Nontaxable Income.

When you exercise an ISO, you may have to include in alternative minimum taxable income a portion of the fair market value (FMV) of the stock acquired through the exercise of the option. For more information, see Form 6251, Alternative Minimum Tax—Individuals, and its instructions.

Employee’s taxpayer identification number (TIN). For your protection, this form may show only the last four digits of your social security number (SSN), individual taxpayer identification number (ITIN), or adoption taxpayer identification number (ATIN). However, the employer has reported your complete TIN to the IRS.

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 exercise price per share of stock.

Box 4. Shows the FMV of a share of stock on the date the option was exercised.

Box 5. Shows the number of shares of stock transferred to you pursuant to the exercise of the option.

Box 6. Shows the name, address, and TIN of the corporation whose stock is being transferred (if other than the corporation shown in TRANSFEROR boxes in the upper left corner of the form).

Future developments. For the latest information about developments related to Form 3921 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/Form3921 .

Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost online federal tax preparation, e-filing, and direct deposit or payment options.

CORRECTED (if checked)

Exercise of an

Option Under Section 422(b)

Copy C For Corporation

This copy should be retained by the corporation whose

stock has been transferred under

Section 422(b).

TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code		1 Date option granted	OMB No. 1545-2129 Form 3921 (Rev. April 2025)
TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	TRANSFEROR’S name, street address, city or town, state or province, country, and ZIP or foreign postal code	2 Date option exercised	2 Date option exercised
TRANSFEROR’S TIN	EMPLOYEE’S TIN	3 Exercise price per share $	4 Fair market value per share on exercise date $
EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code
EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	5 No. of shares transferred
EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	EMPLOYEE’S name Street address (including apt. no.) City or town,state or province, country, and ZIP or foreign postal code	6 If other than TRANSFEROR, name, address, and TIN of corporation whose stock is being transferred	6 If other than TRANSFEROR, name, address, and TIN of corporation whose stock is being transferred
Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)

Department of the Treasury - Internal Revenue Service