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This is a SAMPLE form to help you complete your I-765.
Each page of this PDF will help you complete each section. It is VERY important that this form is filled out correctly. It will cost an additional $380 to
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Form 3921 (Rev. April 2025)
You have received this form because your employer (or transfer agent) transferred your employers stock to you pursuant to your exercise of an incentive stock
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Sample release form
*Note: This is a sample release. You will need to identify appropriate language for your circumstances. National Institutes of Health.
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