| |
Employer:
| |
Employer Identification Number (EIN):
00-4276099 |
SAMPLE PAYER 1 | |
1597 PARK ST | |
BIRMINGHAM, AL 35064 | |
| |
Employee:
| |
Employee's Social Security Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $2,940.00 |
Federal Income Tax Withheld: | $169.00 |
Social Security Wages: | $2,940.00 |
Social Security Tax Withheld: | $123.00 |
Medicare Wages and Tips: | $2,940.00 |
Medicare Tax Withheld: | $42.00 |
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 |
| |
Employer:
| |
Employer Identification Number (EIN):
00-6409809 |
SAMPLE PAYER 2 | |
3302 FIFTH AVE | |
NEW ORLEANS, LA 70032 | |
| |
Employee:
| |
Employee's Social Security Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $480.00 |
Federal Income Tax Withheld: | $24.00 |
Social Security Wages: | $480.00 |
Social Security Tax Withheld: | $20.00 |
Medicare Wages and Tips: | $480.00 |
Medicare Tax Withheld: | $6.00 |
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 |
| |
Employer:
| |
Employer Identification Number (EIN):
00-7731553 |
SAMPLE PAYER 3 | |
9183 FIFTH ST | |
DETROIT, MI 48216 | |
| |
Employee:
| |
Employee's Social Security Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $3,720.00 |
Federal Income Tax Withheld: | $365.00 |
Social Security Wages: | $3,796.00 |
Social Security Tax Withheld: | $159.00 |
Medicare Wages and Tips: | $3,796.00 |
Medicare Tax Withheld: | $55.00 |
Social Security Tips: | $0.00 |
Allocated Tips: | $0.00 |
Dependent Care Benefits: | $0.00 |
Deferred Compensation: | $76.00 |
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 |
| |
Employer:
| |
Employer Identification Number (EIN):
00-1121916 |
SAMPLE PAYER 4 | |
5968 MAPLE AVE | |
LOS ANGELES, CA 90013 | |
| |
Employee:
| |
Employee's Social Security Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $76.00 |
Federal Income Tax Withheld: | $0.00 |
Social Security Wages: | $76.00 |
Social Security Tax Withheld: | $3.00 |
Medicare Wages and Tips: | $76.00 |
Medicare Tax Withheld: | $1.00 |
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 |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-7024768 |
SAMPLE PAYER 5 | |
6803 HILL AVE | |
DALLAS, TX 75089 | |
| |
Recipient:
| |
Recipient's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
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: | 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: | $7,416.00 |
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 |