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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, 2019

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-4600117
SAMPLE PAYER 1
9273 WASHINGTON AVE
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:$21,081.00
Federal Income Tax Withheld:$2,885.00
Social Security Wages:$22,928.00
Social Security Tax Withheld:$1,421.00
Medicare Wages and Tips:$22,928.00
Medicare Tax Withheld:$332.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$1,847.00
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:$8,302.00
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
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

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-0307412
SAMPLE PAYER 2
7071 SEVENTH 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:$49,855.00
Federal Income Tax Withheld:$7,125.00
Social Security Wages:$52,188.00
Social Security Tax Withheld:$3,235.00
Medicare Wages and Tips:$52,188.00
Medicare Tax Withheld:$756.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$2,333.00
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:$16,570.00
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
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

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-8522235
SAMPLE PAYER 3
3908 FOURTH AVE
TAMPA, FL 33607

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:$25,942.00
Federal Income Tax Withheld:$2,919.00
Social Security Wages:$25,942.00
Social Security Tax Withheld:$1,608.00
Medicare Wages and Tips:$25,942.00
Medicare Tax Withheld:$376.00
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
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

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-6677714
SAMPLE PAYER 4
6691 SECOND 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:$21,702.00
Federal Income Tax Withheld:$1,611.00
Social Security Wages:$22,373.00
Social Security Tax Withheld:$1,387.00
Medicare Wages and Tips:$22,373.00
Medicare Tax Withheld:$324.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$671.00
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
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

Form 1098 Mortgage Interest Statement

Recipient/Lender:

Recipient's Federal Identification Number (FIN): 00-2043120
SAMPLE PAYER 5
9317 MAIN ST
BOSTON, MA 02123

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):$1,018.00
Points Paid on Purchase of Principal Residence:$0.00
Refund of Overpaid Interest:$0.00
Mortgage Insurance Premiums:$0.00
Outstanding Mortgage Principle:$0.00
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

Form 1099-INT

Payer:

Payer's Federal Identification Number (FIN): 00-9053892
SAMPLE PAYER 6
6622 WASHINGTON ST
NEW YORK, NY 10005

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:$100.00
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

Form 1099-R Distributions from Pensions, Annuities, Retire or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Payer:

Payer's Federal Identification Number (FIN): 00-6679000
SAMPLE PAYER 7
9920 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
Distribution Code Value:Normal distribution
Distribution Code:7
Distribution Code Value:Not significant
Distribution Code:Blank
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:$8,766.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$43,830.00
Taxable Amount:$43,830.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

Form 1099-R Distributions from Pensions, Annuities, Retire or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Payer:

Payer's Federal Identification Number (FIN): 00-5119868
SAMPLE PAYER 8
4755 EIGHTH ST
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:Normal distribution
Distribution Code:7
Distribution Code Value:Not significant
Distribution Code:Blank
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:$5,222.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$26,113.00
Taxable Amount:$26,113.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

Form 1099-R Distributions from Pensions, Annuities, Retire or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Payer:

Payer's Federal Identification Number (FIN): 00-9223928
SAMPLE PAYER 9
1049 EIGHTH AVE
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
Distribution Code Value:Normal distribution
Distribution Code:7
Distribution Code Value:Not significant
Distribution Code:Blank
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:$732.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$3,663.00
Taxable Amount:$3,663.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

Form 1099-R Distributions from Pensions, Annuities, Retire or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Payer:

Payer's Federal Identification Number (FIN): 00-3632919
SAMPLE PAYER 10
9676 MAPLE 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:Normal distribution
Distribution Code:7
Distribution Code Value:Not significant
Distribution Code:Blank
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:$4,005.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$20,025.00
Taxable Amount:$20,025.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

Form 1099-R Distributions from Pensions, Annuities, Retire or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Payer:

Payer's Federal Identification Number (FIN): 00-5693430
SAMPLE PAYER 11
8657 CEDAR ST
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
Distribution Code Value:Normal distribution
Distribution Code:7
Distribution Code Value:Not significant
Distribution Code:Blank
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:$739.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$3,696.00
Taxable Amount:$3,696.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

This Product Contains Sensitive Taxpayer Data