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This Product Contains Sensitive Taxpayer Data

Wage and Income Transcript

Request Date: 04-28-2022
Response Date: 04-28-2022
Tracking Number: 999999999999

SSN Provided: 976-00-1879
Tax Period Requested: December, 2013

Form SSA-1099 Benefits Statement

Payer:

Payer's Federal Identification Number (FIN): 00-3109112
SAMPLE PAYER 1

Payee:

Payee's Identification Number: 976-00-1879
BRIAN MARTIN
7967 MAPLE ST
KNOXVILLE, TN 37918

Submission Type: Original document
Account Number (Optional): N/A
Pensions and Annuities (Total Benefits Paid): $20,722.00
Tax Withheld: 0.00
Repayments: 0.00
Workman's Compensation Offset: 0.00
TY 2012 Payments: 0.00
TY 2011 Payments: 0.00
TY 2010 Payments: 0.00
TY 2009 Payments: 0.00
Trust Fund Indicator: Disability
SSA/RRB Payments: Either RRB or SSA payments

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

Payer:

Payer's Federal Identification Number (FIN): 00-3521985
SAMPLE PAYER 2
7196 PINE ST
AKRON, OH 44223

Recipient:

Recipient's Identification Number: 976-00-1879
BRIAN MARTIN
7967 MAPLE ST
KNOXVILLE, TN 37918

Submission Type:Original document
Account Number (Optional):999999999
Distribution Code Value:Disability
Distribution Code:3
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
Tax Withheld:$2,397.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$11,989.00
Taxable Amount:$11,989.00
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): 00-6875722
SAMPLE PAYER 3
4050 MAPLE AVE
AKRON, OH 44223

Recipient:

Recipient's Identification Number: 976-00-1879
BRIAN MARTIN
7967 MAPLE ST
KNOXVILLE, TN 37918

Submission Type:Original document
Account Number (Optional):999999999
Distribution Code Value:Disability
Distribution Code:3
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
Tax Withheld:$300.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$14,958.00
Taxable Amount:$14,958.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

This Product Contains Sensitive Taxpayer Data