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This Product Contains Sensitive Taxpayer Data

Wage and Income Transcript

Request Date: 11-10-2021
Response Date: 11-10-2021
Tracking Number: 999999999999

SSN Provided: 342-00-5838
Tax Period Requested: December, 2012

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-1795316
SAMPLE PAYER 1
5222 EIGHTH AVE
NEW ORLEANS, LA 70032

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:$73,690.00
Federal Income Tax Withheld:$11,071.00
Social Security Wages:$73,690.00
Social Security Tax Withheld:$3,095.00
Medicare Wages and Tips:$73,690.00
Medicare Tax Withheld:$1,068.00
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

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-4451375
SAMPLE PAYER 2
3472 SECOND ST
DETROIT, MI 48216

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:$65,353.00
Federal Income Tax Withheld:$9,054.00
Social Security Wages:$68,581.00
Social Security Tax Withheld:$2,880.00
Medicare Wages and Tips:$68,581.00
Medicare Tax Withheld:$994.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$3,227.00
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:$22,329.00
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

Form 1098-T

Payer:

Payer's Federal Identification Number (FIN): 00-7694253
SAMPLE PAYER 3
8285 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):
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
Amounts Billed for Qualified Tuition & Related Expenses:$0.00
Adjustments Made for Prior Year:$2,652.00
Adjustments to Scholarships or Grants for a Prior Year:$0.00
Reimbursements/Refunds from an Insurance Contract:$0.00

Form 1099-G

Payer:

Payer's Federal Identification Number (FIN): 00-5841904
SAMPLE PAYER 4
9727 PINE ST
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
ATAA Payments:$0.00
Tax Withheld:$0.00
Taxable Grants:$0.00
Unemployment Compensation:$0.00
Agricultural Subsidies:$0.00
Prior Year Refund:$136.00
Market gain on Commodity Credit Corporation loans repaid:$0.00
Year of Refund:2011
1099G Offset:Not Refund, Credit, or Offset for Trade or Business

This Product Contains Sensitive Taxpayer Data