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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, 2016

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-1935328
SAMPLE PAYER 1
5754 MAPLE 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:$80,149.00
Federal Income Tax Withheld:$11,868.00
Social Security Wages:$83,694.00
Social Security Tax Withheld:$5,189.00
Medicare Wages and Tips:$83,694.00
Medicare Tax Withheld:$1,213.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$3,544.00
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:$23,798.00
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
W2 Submission Type:Original
W2 WHC SSN Validation Code:Correct SSN

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-8010210
SAMPLE PAYER 2
9025 PARK ST
ATLANTA, GA 30305

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:$7,196.00
Federal Income Tax Withheld:$787.00
Social Security Wages:$7,196.00
Social Security Tax Withheld:$446.00
Medicare Wages and Tips:$7,196.00
Medicare Tax Withheld:$104.00
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
W2 Submission Type:Original
W2 WHC SSN Validation Code:Correct SSN

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-4152170
SAMPLE PAYER 3
9481 MAIN ST
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:$34,987.00
Federal Income Tax Withheld:$3,288.00
Social Security Wages:$36,001.00
Social Security Tax Withheld:$2,232.00
Medicare Wages and Tips:$36,001.00
Medicare Tax Withheld:$522.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$1,013.00
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
W2 Submission Type:Original
W2 WHC SSN Validation Code:Correct SSN

Form 1098-T

Payer:

Payer's Federal Identification Number (FIN): 00-7419647
SAMPLE PAYER 4
6811 SECOND AVE
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
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
TIN Checkbox:box marked
Amounts Billed for Qualified Tuition & Related Expenses:$150.00
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

Form 1098-T

Payer:

Payer's Federal Identification Number (FIN): 00-7348424
SAMPLE PAYER 5
9062 THIRD ST
KANSAS CITY, MO 64112

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:$8,079.00
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
TIN Checkbox:box marked
Amounts Billed for Qualified Tuition & Related Expenses:$8,514.00
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

Form 1098-T

Payer:

Payer's Federal Identification Number (FIN): 00-2309874
SAMPLE PAYER 6
4673 SIXTH AVE
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
Qualified Tuition and Related Expense:$35.00
Scholarships or Grants:$0.00
Half Time Student Indicator:Less Than 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
TIN Checkbox:box marked
Amounts Billed for Qualified Tuition & Related Expenses:$0.00
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

Form 1099-G

Payer:

Payer's Federal Identification Number (FIN): 00-3522967
SAMPLE PAYER 7
6274 ELM AVE
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
ATAA Payments:$0.00
Tax Withheld:$0.00
Taxable Grants:$0.00
Unemployment Compensation:$0.00
Agricultural Subsidies:$0.00
Prior Year Refund:$40.00
Market gain on Commodity Credit Corporation loans repaid:$0.00
Year of Refund:2015
1099G Offset:Not Refund, Credit, or Offset for Trade or Business

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

Payer:

Payer's Federal Identification Number (FIN): 00-6616584
SAMPLE PAYER 8
4119 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):999999999
Distribution Code Value:Loans treated as deemed distributions under section 72(p)
Distribution Code:L
Distribution Code Value:Early Distribution, no known exception (in most cases, under age 59 1/2)
Distribution Code:1
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:$0.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$14,249.00
Taxable Amount:$14,249.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

This Product Contains Sensitive Taxpayer Data