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Employer:
| |
Employer Identification Number (EIN):
00-1795316 |
SAMPLE PAYER 1 | |
5222 EIGHTH AVE | |
NEW ORLEANS, LA 70032 | |
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Employee:
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Employee's Social Security Number:
342-00-5838 |
DANIEL WASHINGTON | |
8676 HAMPSHIRE GLEN DR S | |
JACKSONVILLE, FL 32256 | |
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Submission Type: | Original document |
Wages, Tips and Other Compensation: | $73,690.00 |
Federal Income Tax Withheld: | $11,071.00 |
Social Security Wages: | $73,690.00 |
Social Security Tax Withheld: | $3,095.00 |
Medicare Wages and Tips: | $73,690.00 |
Medicare Tax Withheld: | $1,068.00 |
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 |
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Employer:
| |
Employer Identification Number (EIN):
00-4451375 |
SAMPLE PAYER 2 | |
3472 SECOND ST | |
DETROIT, MI 48216 | |
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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: | $65,353.00 |
Federal Income Tax Withheld: | $9,054.00 |
Social Security Wages: | $68,581.00 |
Social Security Tax Withheld: | $2,880.00 |
Medicare Wages and Tips: | $68,581.00 |
Medicare Tax Withheld: | $994.00 |
Social Security Tips: | $0.00 |
Allocated Tips: | $0.00 |
Dependent Care Benefits: | $0.00 |
Deferred Compensation: | $3,227.00 |
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: | $22,329.00 |
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 |
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Payer:
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Payer's Federal Identification Number (FIN):
00-7694253 |
SAMPLE PAYER 3 | |
8285 LAKE AVE | |
CHICAGO, IL 60603 | |
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Recipient:
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Recipient's Identification Number:
342-00-5838 |
DANIEL WASHINGTON | |
8676 HAMPSHIRE GLEN DR S | |
JACKSONVILLE, FL 32256 | |
| |
Submission Type: | Original document |
Account Number (Optional): | |
Qualified Tuition and Related Expense: | $0.00 |
Scholarships or Grants: | $0.00 |
Half Time Student Indicator: | Less Than 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: | $0.00 |
Adjustments Made for Prior Year: | $2,652.00 |
Adjustments to Scholarships or Grants for a Prior Year: | $0.00 |
Reimbursements/Refunds from an Insurance Contract: | $0.00 |