| |
Employer:
| |
Employer Identification Number (EIN):
00-0801787 |
SAMPLE PAYER 1 | |
8228 MAIN AVE | |
BOSTON, MA 02123 | |
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Employee:
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Employee's Social Security Number:
707-00-8679 |
BRIAN TAYLOR | |
8721 Flint Falls Dr | |
DALLAS, TX 75243 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $105,208.00 |
Federal Income Tax Withheld: | $8,505.00 |
Social Security Wages: | $105,208.00 |
Social Security Tax Withheld: | $6,522.00 |
Medicare Wages and Tips: | $105,208.00 |
Medicare Tax Withheld: | $1,525.00 |
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 |
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Trustee:
| |
Trustee/Issuer's Federal Identification Number (FIN):
00-2316856 |
SAMPLE PAYER 2 | |
4165 MAPLE AVE | |
PHOENIX, AZ 85005 | |
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Participant:
| |
Participant's Identification Number:
707-00-8679 |
BRIAN TAYLOR | |
8721 Flint Falls Dr | |
DALLAS, TX 75243 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
IRA Contributions: | $0.00 |
Rollover Contributions: | $0.00 |
Roth Conversion Amount: | $0.00 |
Recharacterized Contributions: | $0.00 |
Fair Market Value of Account: | $15.00 |
Life Insurance Cost Included in Box 1: | $0.00 |
SEP Code: | Not Checked |
IRA Code: | Checked |
Simple Code: | Not Checked |
Roth IRA Code: | Not Checked |
RMD For Subsequent Year: | RMD box not checked |
RMD Date: | 00-00-0000 |
Year: | |
Postponed Contribution Code: | |
Repayments Code: | |
Fair Market Value of certain specified assets: | N/A |
SEP Contributions: | $0.00 |
SIMPLE Contributions: | $0.00 |
Roth IRA Contributions: | $0.00 |
Required Minimum Distribution Amount: | $0.00 |
Postponed Contributions: | $0.00 |
Repayment of a qualified reservist distribution or federally designated disaster withdrawal repayment: | $0.00 |
Fair Market Value of Certain Specified Assets: | $0.00 |
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Payer:
| |
Payer's Federal Identification Number (FIN):
00-6815480 |
SAMPLE PAYER 4 | |
1921 MAPLE AVE | |
NEW ORLEANS, LA 70032 | |
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Recipient:
| |
Recipient's Identification Number:
707-00-8679 |
BRIAN TAYLOR | |
8721 Flint Falls Dr | |
DALLAS, TX 75243 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Interest: | $0.00 |
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 |