| |
Employer:
| |
Employer Identification Number (EIN):
00-5005732 |
SAMPLE PAYER 1 | |
9643 VIEW ST | |
LOS ANGELES, CA 90013 | |
| |
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: | $49,443.00 |
Federal Income Tax Withheld: | $5,718.00 |
Social Security Wages: | $55,498.00 |
Social Security Tax Withheld: | $3,440.00 |
Medicare Wages and Tips: | $55,498.00 |
Medicare Tax Withheld: | $804.00 |
Social Security Tips: | $0.00 |
Allocated Tips: | $0.00 |
Dependent Care Benefits: | $0.00 |
Deferred Compensation: | $6,055.00 |
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: | $24,526.00 |
Code "EE" Designated ROTH Contributions Under a Governmental Section 457(b) Plan: | $0.00 |
Code "FF" Permitted benefits under a qualified small employer health reimbursement arrangement: | $0.00 |
Code "GG" Income from Qualified Equity Grants Under Section 83(i): | $0.00 |
Code "HH" Aggregate Deferrals Under Section 83(i) Elections as of the Close of the Calendar Year: | $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):
00-2741466 |
SAMPLE PAYER 2 | |
6342 FOURTH AVE | |
BOSTON, MA 02123 | |
| |
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: | $3,997.00 |
Federal Income Tax Withheld: | $443.00 |
Social Security Wages: | $4,320.00 |
Social Security Tax Withheld: | $267.00 |
Medicare Wages and Tips: | $4,320.00 |
Medicare Tax Withheld: | $62.00 |
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 |
Code "FF" Permitted benefits under a qualified small employer health reimbursement arrangement: | $0.00 |
Code "GG" Income from Qualified Equity Grants Under Section 83(i): | $0.00 |
Code "HH" Aggregate Deferrals Under Section 83(i) Elections as of the Close of the Calendar Year: | $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):
00-5814532 |
SAMPLE PAYER 3 | |
7080 FIFTH AVE | |
JACKSONVILLE, FL 32034 | |
| |
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: | $25,201.00 |
Federal Income Tax Withheld: | $2,915.00 |
Social Security Wages: | $25,201.00 |
Social Security Tax Withheld: | $1,562.00 |
Medicare Wages and Tips: | $25,201.00 |
Medicare Tax Withheld: | $365.00 |
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 |
Code "FF" Permitted benefits under a qualified small employer health reimbursement arrangement: | $0.00 |
Code "GG" Income from Qualified Equity Grants Under Section 83(i): | $0.00 |
Code "HH" Aggregate Deferrals Under Section 83(i) Elections as of the Close of the Calendar Year: | $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):
00-5776773 |
SAMPLE PAYER 4 | |
1319 MAPLE ST | |
BOSTON, MA 02123 | |
| |
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: | $29,574.00 |
Federal Income Tax Withheld: | $2,736.00 |
Social Security Wages: | $30,488.00 |
Social Security Tax Withheld: | $1,890.00 |
Medicare Wages and Tips: | $30,488.00 |
Medicare Tax Withheld: | $442.00 |
Social Security Tips: | $0.00 |
Allocated Tips: | $0.00 |
Dependent Care Benefits: | $0.00 |
Deferred Compensation: | $914.00 |
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 |
Code "FF" Permitted benefits under a qualified small employer health reimbursement arrangement: | $0.00 |
Code "GG" Income from Qualified Equity Grants Under Section 83(i): | $0.00 |
Code "HH" Aggregate Deferrals Under Section 83(i) Elections as of the Close of the Calendar Year: | $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 |
| |
Recipient/Lender:
| |
Recipient's Federal Identification Number (FIN):
00-4316884 |
SAMPLE PAYER 5 | |
5943 NINTH AVE | |
TAMPA, FL 33607 | |
| |
Payer/Borrower:
| |
Payer's Social Security Number:
342-00-5838 |
DANIEL WASHINGTON | |
8676 HAMPSHIRE GLEN DR S | |
JACKSONVILLE, FL 32256 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Mortgage Interest Received from Payer(s)/Borrower(s): | $13,865.00 |
Points Paid on Purchase of Principal Residence: | $0.00 |
Refund of Overpaid Interest: | $0.00 |
Mortgage Insurance Premiums: | $5,281.00 |
Outstanding Mortgage Principle: | $349,200.00 |
Mortgage Origination Date: | 12-08-2019 |
Property Address Verification: | the address of the property securing the mortgage is the same as the payer's/borrower's |
Address of property securing Mortgage: | |
Description of Property: | |
Other information from recipient: | |
The number of mortgaged properties: | 00000000 |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-9812401 |
SAMPLE PAYER 6 | |
2292 SIXTH ST | |
NEW ORLEANS, LA 70032 | |
| |
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 |
Interest: | $124.00 |
Tax Withheld: | $0.00 |
Savings Bonds: | $0.00 |
Investment Expense: | $0.00 |
Interest Forfeiture: | $0.00 |
Foreign Tax Paid: | $0.00 |
Tax-Exempt Interest: | $0.00 |
Specified Private Activity Bond Interest: | $0.00 |
Market Discount: | $0.00 |
Bond Premium: | $0.00 |
Bond Premium on Tax Exempt Bond: | $0.00 |
Bond Premium on Treasury Obligations: | $0.00 |
Second Notice Indicator: | No Second Notice |
Foreign Country or US Possession: | |
CUSIP Number: | |
FATCA Filing Requirement: | Box not checked no Filing Requirement |