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This Product Contains Sensitive Taxpayer Data

Wage and Income Transcript

Request Date: 11-10-2023
Response Date: 11-10-2023
Tracking Number: 999999999999

SSN Provided: 342-00-5838
Tax Period Requested: December, 2015

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-4177486
SAMPLE PAYER 1
4748 HILL ST
PHOENIX, AZ 85005

Employee:

Employee's Social Security Number: 342-00-5838
DANIEL WASHINGTON
8676 HAMPSHIRE GLEN DR S
JACKSONVILLE, FL 32256

Submission Type:Original document
Wages, Tips and Other Compensation:$62,686.00
Federal Income Tax Withheld:$8,807.00
Social Security Wages:$62,686.00
Social Security Tax Withheld:$3,886.00
Medicare Wages and Tips:$62,686.00
Medicare Tax Withheld:$908.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$0.00
Code "Q" Nontaxable Combat Pay:$0.00
Code "W" Employer Contributions to a Health Savings Account:$0.00
Code "Y" Deferrals under a section 409A nonqualified Deferred Compensation plan:$0.00
Code "Z" Income under section 409A on a nonqualified Deferred Compensation plan:$0.00
Code "R" Employer's Contribution to MSA:$0.00
Code "S" Employer's Contribution to Simple Account:$0.00
Code "T" Expenses Incurred for Qualified Adoptions:$0.00
Code "V" Income from exercise of non-statutory stock options:$0.00
Code "AA" Designated Roth Contributions under a Section 401(k) Plan:$0.00
Code "BB" Designated Roth Contributions under a Section 403(b) Plan:$0.00
Code "DD" Cost of Employer-Sponsored Health Coverage:$0.00
Code "EE" Designated ROTH Contributions Under a Governmental Section 457(b) Plan:$0.00
Third Party Sick Pay Indicator:Unanswered
Retirement Plan Indicator:Unanswered
Statutory Employee:Not Statutory Employee

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-7655028
SAMPLE PAYER 2
6790 OAK AVE
NEW YORK, NY 10005

Employee:

Employee's Social Security Number: 342-00-5838
DANIEL WASHINGTON
8676 HAMPSHIRE GLEN DR S
JACKSONVILLE, FL 32256

Submission Type:Original document
Wages, Tips and Other Compensation:$66,723.00
Federal Income Tax Withheld:$9,177.00
Social Security Wages:$70,006.00
Social Security Tax Withheld:$4,340.00
Medicare Wages and Tips:$70,006.00
Medicare Tax Withheld:$1,015.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$3,283.00
Code "Q" Nontaxable Combat Pay:$0.00
Code "W" Employer Contributions to a Health Savings Account:$0.00
Code "Y" Deferrals under a section 409A nonqualified Deferred Compensation plan:$0.00
Code "Z" Income under section 409A on a nonqualified Deferred Compensation plan:$0.00
Code "R" Employer's Contribution to MSA:$0.00
Code "S" Employer's Contribution to Simple Account:$0.00
Code "T" Expenses Incurred for Qualified Adoptions:$0.00
Code "V" Income from exercise of non-statutory stock options:$0.00
Code "AA" Designated Roth Contributions under a Section 401(k) Plan:$0.00
Code "BB" Designated Roth Contributions under a Section 403(b) Plan:$0.00
Code "DD" Cost of Employer-Sponsored Health Coverage:$21,310.00
Code "EE" Designated ROTH Contributions Under a Governmental Section 457(b) Plan:$0.00
Third Party Sick Pay Indicator:Unanswered
Retirement Plan Indicator:Yes - retirement plan
Statutory Employee:Not Statutory Employee

Form 1098-T

Payer:

Payer's Federal Identification Number (FIN): 00-8568224
SAMPLE PAYER 3
5184 MAPLE AVE
TAMPA, FL 33607

Recipient:

Recipient's Identification Number: 342-00-5838
DANIEL WASHINGTON
8676 HAMPSHIRE GLEN DR S
JACKSONVILLE, FL 32256

Submission Type:Original document
Account Number (Optional):999999999
Qualified Tuition and Related Expense:$0.00
Scholarships or Grants:$0.00
Half Time Student Indicator:Grtr than or Eq to Half Time Student
Graduate Student Indicator:Not a Graduate Student
Academic Period Code:Academic Period Box Not Checked
Method of Reporting Indicator:No Change in Reporting Method from the Previous Year
Amounts Billed for Qualified Tuition & Related Expenses:$3,825.00
Adjustments Made for Prior Year:$0.00
Adjustments to Scholarships or Grants for a Prior Year:$0.00
Reimbursements/Refunds from an Insurance Contract:$0.00

Form 1099-G

Payer:

Payer's Federal Identification Number (FIN): 00-9370856
SAMPLE PAYER 4
3733 PINE ST
JACKSONVILLE, FL 32256

Recipient:

Recipient's Identification Number: 342-00-5838
DANIEL WASHINGTON
8676 HAMPSHIRE GLEN DR S
JACKSONVILLE, FL 32256

Submission Type:Original document
Account Number (Optional):999999999
ATAA Payments:$0.00
Tax Withheld:$0.00
Taxable Grants:$0.00
Unemployment Compensation:$0.00
Agricultural Subsidies:$0.00
Prior Year Refund:$216.00
Market gain on Commodity Credit Corporation loans repaid:$0.00
Year of Refund:2012
1099G Offset:Not Refund, Credit, or Offset for Trade or Business

This Product Contains Sensitive Taxpayer Data