| |
Employer:
| |
Employer Identification Number (EIN):
00-4177486 |
SAMPLE PAYER 1 | |
4748 HILL ST | |
PHOENIX, AZ 85005 | |
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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 | |
| |
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 |
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Employer:
| |
Employer Identification Number (EIN):
00-7655028 |
SAMPLE PAYER 2 | |
6790 OAK AVE | |
NEW YORK, NY 10005 | |
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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: | $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 |
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Payer:
| |
Payer's Federal Identification Number (FIN):
00-8568224 |
SAMPLE PAYER 3 | |
5184 MAPLE AVE | |
TAMPA, FL 33607 | |
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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 |