| |
Employer:
| |
Employer Identification Number (EIN):
00-2983929 |
SAMPLE PAYER 1 | |
6813 OAK AVE | |
PHOENIX, AZ 85005 | |
| |
Employee:
| |
Employee's Social Security Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $30,823.00 |
Federal Income Tax Withheld: | $2,548.00 |
Social Security Wages: | $30,823.00 |
Social Security Tax Withheld: | $1,911.00 |
Medicare Wages and Tips: | $30,823.00 |
Medicare Tax Withheld: | $446.00 |
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 |
| |
Employer:
| |
Employer Identification Number (EIN):
00-0184272 |
SAMPLE PAYER 2 | |
2809 WASHINGTON ST | |
KANSAS CITY, MO 64112 | |
| |
Employee:
| |
Employee's Social Security Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $3,923.00 |
Federal Income Tax Withheld: | $341.00 |
Social Security Wages: | $3,923.00 |
Social Security Tax Withheld: | $243.00 |
Medicare Wages and Tips: | $3,923.00 |
Medicare Tax Withheld: | $56.00 |
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 |
| |
Employer:
| |
Employer Identification Number (EIN):
00-0405219 |
SAMPLE PAYER 3 | |
1918 EIGHTH ST | |
LOS ANGELES, CA 90013 | |
| |
Employee:
| |
Employee's Social Security Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Wages, Tips and Other Compensation: | $1,151.00 |
Federal Income Tax Withheld: | $73.00 |
Social Security Wages: | $1,151.00 |
Social Security Tax Withheld: | $71.00 |
Medicare Wages and Tips: | $1,151.00 |
Medicare Tax Withheld: | $16.00 |
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 |