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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, 2018

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-5005732
SAMPLE PAYER 1
9643 VIEW ST
LOS ANGELES, CA 90013

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:$49,443.00
Federal Income Tax Withheld:$5,718.00
Social Security Wages:$55,498.00
Social Security Tax Withheld:$3,440.00
Medicare Wages and Tips:$55,498.00
Medicare Tax Withheld:$804.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$6,055.00
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:$24,526.00
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

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-2741466
SAMPLE PAYER 2
6342 FOURTH AVE
BOSTON, MA 02123

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:$3,997.00
Federal Income Tax Withheld:$443.00
Social Security Wages:$4,320.00
Social Security Tax Withheld:$267.00
Medicare Wages and Tips:$4,320.00
Medicare Tax Withheld:$62.00
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: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): 00-5814532
SAMPLE PAYER 3
7080 FIFTH AVE
JACKSONVILLE, FL 32034

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:$25,201.00
Federal Income Tax Withheld:$2,915.00
Social Security Wages:$25,201.00
Social Security Tax Withheld:$1,562.00
Medicare Wages and Tips:$25,201.00
Medicare Tax Withheld:$365.00
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

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN): 00-5776773
SAMPLE PAYER 4
1319 MAPLE ST
BOSTON, MA 02123

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:$29,574.00
Federal Income Tax Withheld:$2,736.00
Social Security Wages:$30,488.00
Social Security Tax Withheld:$1,890.00
Medicare Wages and Tips:$30,488.00
Medicare Tax Withheld:$442.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$0.00
Deferred Compensation:$914.00
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

Form 1098 Mortgage Interest Statement

Recipient/Lender:

Recipient's Federal Identification Number (FIN): 00-4316884
SAMPLE PAYER 5
5943 NINTH AVE
TAMPA, FL 33607

Payer/Borrower:

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):$13,865.00
Points Paid on Purchase of Principal Residence:$0.00
Refund of Overpaid Interest:$0.00
Mortgage Insurance Premiums:$5,281.00
Outstanding Mortgage Principle:$349,200.00
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

Form 1099-INT

Payer:

Payer's Federal Identification Number (FIN): 00-9812401
SAMPLE PAYER 6
2292 SIXTH ST
NEW ORLEANS, LA 70032

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:$124.00
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

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

Payer:

Payer's Federal Identification Number (FIN): 00-6674312
SAMPLE PAYER 7
6919 MAIN AVE
BOSTON, MA 02123

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:Normal distribution
Distribution Code:7
Distribution Code Value:Not significant
Distribution Code:Blank
Tax Amount Undetermined Code:Not checked
Total Distribution Code:Total Distribution
First Year Roth Contribution:0000
SEP Indicator:IRA/SEP/SIMP box not checked
FATCA Indicator:not FATCA
Date of Payment for Reportable Death Benefits under Section 6050Y:00-00-0000
Tax Withheld:$1,662.00
Total Employee Contributions:$0.00
Unrealized Appreciation:$0.00
Other Income:$0.00
Gross Distribution:$8,313.00
Taxable Amount:$8,313.00
Eligible Capital Gains:$0.00
Amount to IRR:$0.00

This Product Contains Sensitive Taxpayer Data