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This Product Contains Sensitive Taxpayer Data

Wage and Income Transcript

Request Date: 12-30-2021
Response Date: 12-30-2021
Tracking Number: 999999999999

SSN Provided: 976-00-1879
Tax Period Requested: December, 2011

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-6052210
SAMPLE PAYER 1
9589 NINTH AVE
BIRMINGHAM, AL 35064

Employee:

Employee's Social Security Number: 976-00-1879
BRIAN MARTIN
7967 MAPLE ST
KNOXVILLE, TN 37918

Submission Type:Original document
Wages, Tips and Other Compensation:$13,804.00
Federal Income Tax Withheld:$1,931.00
Social Security Wages:$13,804.00
Social Security Tax Withheld:$579.00
Medicare Wages and Tips:$13,804.00
Medicare Tax Withheld:$200.00
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:Yes - retirement plan
Statutory Employee:Not Statutory Employee

Form SSA-1099 Benefits Statement

Payer:

Payer's Federal Identification Number (FIN): 00-2615374
SAMPLE PAYER 2

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): $18,760.00
Tax Withheld: 0.00
Repayments: 0.00
Workman's Compensation Offset: 0.00
TY 2010 Payments: 0.00
TY 2009 Payments: 0.00
TY 2008 Payments: 0.00
TY 2007 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): 00-7904828
SAMPLE PAYER 3
2526 FIRST ST
PHOENIX, AZ 85005

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:$0.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$1,871.00
Taxable Amount:$1,871.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

This Product Contains Sensitive Taxpayer Data