| |
Employer:
| |
Employer Identification Number (EIN):
00-1935328 |
SAMPLE PAYER 1 | |
5754 MAPLE ST | |
CHICAGO, IL 60603 | |
| |
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: | $80,149.00 |
Federal Income Tax Withheld: | $11,868.00 |
Social Security Wages: | $83,694.00 |
Social Security Tax Withheld: | $5,189.00 |
Medicare Wages and Tips: | $83,694.00 |
Medicare Tax Withheld: | $1,213.00 |
Social Security Tips: | $0.00 |
Allocated Tips: | $0.00 |
Dependent Care Benefits: | $0.00 |
Deferred Compensation: | $3,544.00 |
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: | $23,798.00 |
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 |
W2 Submission Type: | Original |
W2 WHC SSN Validation Code: | Correct SSN |
| |
Employer:
| |
Employer Identification Number (EIN):
00-8010210 |
SAMPLE PAYER 2 | |
9025 PARK ST | |
ATLANTA, GA 30305 | |
| |
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: | $7,196.00 |
Federal Income Tax Withheld: | $787.00 |
Social Security Wages: | $7,196.00 |
Social Security Tax Withheld: | $446.00 |
Medicare Wages and Tips: | $7,196.00 |
Medicare Tax Withheld: | $104.00 |
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 |
W2 Submission Type: | Original |
W2 WHC SSN Validation Code: | Correct SSN |
| |
Employer:
| |
Employer Identification Number (EIN):
00-4152170 |
SAMPLE PAYER 3 | |
9481 MAIN 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: | $34,987.00 |
Federal Income Tax Withheld: | $3,288.00 |
Social Security Wages: | $36,001.00 |
Social Security Tax Withheld: | $2,232.00 |
Medicare Wages and Tips: | $36,001.00 |
Medicare Tax Withheld: | $522.00 |
Social Security Tips: | $0.00 |
Allocated Tips: | $0.00 |
Dependent Care Benefits: | $0.00 |
Deferred Compensation: | $1,013.00 |
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: | Yes - retirement plan |
Statutory Employee: | Not Statutory Employee |
W2 Submission Type: | Original |
W2 WHC SSN Validation Code: | Correct SSN |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-7419647 |
SAMPLE PAYER 4 | |
6811 SECOND AVE | |
PHOENIX, AZ 85005 | |
| |
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: | 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 |
TIN Checkbox: | box marked |
Amounts Billed for Qualified Tuition & Related Expenses: | $150.00 |
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 |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-7348424 |
SAMPLE PAYER 5 | |
9062 THIRD ST | |
KANSAS CITY, MO 64112 | |
| |
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: | $8,079.00 |
Half Time Student Indicator: | Grtr than or Eq to Half Time Student |
Graduate Student Indicator: | Graduate Student |
Academic Period Code: | Academic Period Box Not Checked |
Method of Reporting Indicator: | No Change in Reporting Method from the Previous Year |
TIN Checkbox: | box marked |
Amounts Billed for Qualified Tuition & Related Expenses: | $8,514.00 |
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 |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-2309874 |
SAMPLE PAYER 6 | |
4673 SIXTH AVE | |
BIRMINGHAM, AL 35064 | |
| |
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: | $35.00 |
Scholarships or Grants: | $0.00 |
Half Time Student Indicator: | Less Than Half Time Student |
Graduate Student Indicator: | Graduate Student |
Academic Period Code: | Academic Period Box Not Checked |
Method of Reporting Indicator: | No Change in Reporting Method from the Previous Year |
TIN Checkbox: | box marked |
Amounts Billed for Qualified Tuition & Related Expenses: | $0.00 |
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 |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-6616584 |
SAMPLE PAYER 8 | |
4119 LAKE AVE | |
CHICAGO, IL 60603 | |
| |
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 |
Distribution Code Value: | Loans treated as deemed distributions under section 72(p) |
Distribution Code: | L |
Distribution Code Value: | Early Distribution, no known exception (in most cases, under age 59 1/2) |
Distribution Code: | 1 |
Tax Amount Undetermined Code: | Not checked |
Total Distribution Code: | Not checked |
First Year Roth Contribution: | 0000 |
SEP Indicator: | IRA/SEP/SIMP box not checked |
FATCA Indicator: | not FATCA |
Tax Withheld: | $0.00 |
Total Employee Contributions: | $0.00 |
Unrealized Appreciation: | $0.00 |
Other Income: | $0.00 |
Gross Distribution: | $14,249.00 |
Taxable Amount: | $14,249.00 |
Eligible Capital Gains: | $0.00 |
Amount to IRR: | $0.00 |