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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, 2020

Form SSA-1099 Benefits Statement

Payer:

Payer's Federal Identification Number (FIN): 00-2504890
SOCIAL SECURITY ADMINISTRATION

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): $22,855.00
Tax Withheld: 0.00
Repayments: 0.00
Workman's Compensation Offset: 0.00
TY 2019 Payments: 0.00
TY 2018 Payments: 0.00
TY 2017 Payments: 0.00
TY 2016 Payments: 0.00
Trust Fund Indicator: Retirement
SSA/RRB Payments: Either RRB or SSA payments

Form 1099-INT

Payer:

Payer's Federal Identification Number (FIN): 00-8885740
CAPITAL ONE BANK
4851 COX RD
GLEN ALLEN, VA 23058

Recipient:

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

Submission Type:Original document
Account Number (Optional): 99925987456
Interest:$200.00
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): 00-1617082
SAMPLE PAYER 3
9215 SIXTH ST
DETROIT, MI 48216

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:Normal distribution
Distribution Code:7
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
FATCA Indicator:not FATCA
Date of Payment for Reportable Death Benefits under Section 6050Y:00-00-0000
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