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Employer:
| |
Employer Identification Number (EIN):
00-5754430 |
SAMPLE PAYER 1 | |
1136 SIXTH AVE | |
NEW ORLEANS, LA 70032 | |
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Employee:
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Employee's Social Security Number:
342-00-5838 |
DANIEL WASHINGTON | |
8676 HAMPSHIRE GLEN DR S | |
JACKSONVILLE, FL 32256 | |
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Submission Type: | Original document |
Wages, Tips and Other Compensation: | $57,869.00 |
Federal Income Tax Withheld: | $6,440.00 |
Social Security Wages: | $62,672.00 |
Social Security Tax Withheld: | $3,885.00 |
Medicare Wages and Tips: | $62,672.00 |
Medicare Tax Withheld: | $908.00 |
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: | $19,202.00 |
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: | Yes - retirement plan |
Statutory Employee: | Not Statutory Employee |
W2 Submission Type: | Original |
W2 WHC SSN Validation Code: | Correct SSN |
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Employer:
| |
Employer Identification Number (EIN):
00-1072430 |
SAMPLE PAYER 2 | |
3454 EIGHTH ST | |
JACKSONVILLE, FL 32034 | |
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Employee:
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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: | $10,786.00 |
Federal Income Tax Withheld: | $1,185.00 |
Social Security Wages: | $10,786.00 |
Social Security Tax Withheld: | $668.00 |
Medicare Wages and Tips: | $10,786.00 |
Medicare Tax Withheld: | $156.00 |
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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Employer:
| |
Employer Identification Number (EIN):
00-1081642 |
SAMPLE PAYER 3 | |
4219 LAKE AVE | |
PHOENIX, AZ 85005 | |
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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: | $60,138.00 |
Federal Income Tax Withheld: | $7,409.00 |
Social Security Wages: | $62,383.00 |
Social Security Tax Withheld: | $3,867.00 |
Medicare Wages and Tips: | $62,383.00 |
Medicare Tax Withheld: | $904.00 |
Social Security Tips: | $0.00 |
Allocated Tips: | $0.00 |
Dependent Care Benefits: | $0.00 |
Deferred Compensation: | $2,245.00 |
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: | Yes - retirement plan |
Statutory Employee: | Not Statutory Employee |
W2 Submission Type: | Original |
W2 WHC SSN Validation Code: | Correct SSN |
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Recipient/Lender:
| |
Recipient's Federal Identification Number (FIN):
00-8509003 |
SAMPLE PAYER 4 | |
7373 MAPLE AVE | |
LOS ANGELES, CA 90013 | |
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Payer/Borrower:
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Payer's Social Security Number:
342-00-5838 |
DANIEL WASHINGTON | |
8676 HAMPSHIRE GLEN DR S | |
JACKSONVILLE, FL 32256 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Mortgage Interest Received from Payer(s)/Borrower(s): | $14,777.00 |
Points Paid on Purchase of Principal Residence: | $0.00 |
Refund of Overpaid Interest: | $0.00 |
Mortgage Insurance Premiums: | $5,761.00 |
Outstanding Mortgage Principle: | $341,267.00 |
Mortgage Origination Date: | 12-08-2017 |
Property Address Verification: | the address of the property securing the mortgage is the same as the payer's/borrower's |
Address of property securing Mortgage: | |
Description of Property: | |
Other information from recipient: | |
The number of mortgaged properties: | 00000000 |
Mortgage Acquisition Date: | 00-00-0000 |
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Payer:
| |
Payer's Federal Identification Number (FIN):
00-6368182 |
SAMPLE PAYER 5 | |
2422 FOURTH AVE | |
JACKSONVILLE, FL 32256 | |
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Recipient:
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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: | $6,878.00 |
Scholarships or Grants: | $1,604.00 |
Half Time Student Indicator: | Less Than Half Time Student |
Graduate Student Indicator: | Graduate Student |
Academic Period Code: | Amt in Box 1 or 2 is for Period beg Jan - Mar Next Tax Year |
TIN Checkbox: | box marked |
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 |
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Payer:
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Payer's Federal Identification Number (FIN):
00-8304339 |
SAMPLE PAYER 6 | |
7723 SECOND ST | |
CHICAGO, IL 60603 | |
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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 |
Interest: | $51.00 |
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 |