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pdfCORRECTED (if checked)
PAYER'S name, street address, city, state, and ZIP code
1 Gross distribution
Harris Trust
$
OMB No. 1545-0119
13,223
2008
2a Taxable amount
Distributions From Pensions,
Annuities, Retirement or ProfitSharing Plans, IRAs, Insurance
Contracts, etc.
P.O. Box 1389
13,223 Form 1099-R
$
Your City, GA 30308
2b Taxable amount
not determined
Total
distribution
PAYER'S Federal identification
RECIPIENT'S identification 3 Capital gain (included
number
number
in box 2a)
00-123456
876-00-6251
$
$
5 Employee contributions
or insurance premiums
6 Net unrealized
appreciation in
employer's securities
$
8 Other
RECIPIENT'S name
withheld
Troy McCook
$
Street Address (including apt. no)
7 Distribution IRA/
code(s)
30911 Bard Rd
4 Federal income tax
SEP/
SIMPLE
$
City, state, and ZIP code
Your City, GA 30308
Account number (see instructions)
%
9a Your percentage of total
distribution
%
9b Total employee contributions
10 State tax withheld
11 State/Payer's state no.
$
YS 123456
This information is
being furnished to the
Internal Revenue
Service.
$
$
13 Local tax withheld
$
$
Form 1099-R
Copy B
Report this income
on your federal tax
return. If this form
shows federal
income tax withheld
0 in box 4, attach this
copy to your return.
12 State distribution
$13,223
$
14 Name of locality
15 Local distribution
$
$
Department of the Treasury - Internal Revenue Service
Name: Mary J. Hood
DOB: 12/12/1964
SS#895-00-9015
Employment: Operator
Marital Status: Divorced
Spouse’s name (if any): None
People who lived in the house with you and anyone living outside of your home that you
or your spouse (if any) supported during the tax year:
Name
SS#
DOB
Relationship
Lauren Salem
824-00-3571 05/03/1990 Daughter
William Hood
816-00-2643 02/15/1992
Son
You are employed as an operator at Bluefield Telecommunications, and this is your only
source of income. Both of your children, Lauren and William, lived with you full time in
the family home for the entire tax year. You are divorced and provide all of your
children’s support. You and your children lived in the state of Georgia all year and are
U.S. Citizens. Georgia has a state income tax.
fictitious data
a Control number
22222
For Official Use Only
Void
OMB NO. 1545-0008
1 Wages, tips, other compensation
b Employer identification number (EIN)
04-12345
2 Federal income tax withheld
$24,612.00
c Employer's name, address, and ZIP code
Bluefield Telecommunications
$687.00
4 Social security tax withheld
3 Social security wages
$1,525.94
$24,612.00
5 Medicare wages and tips
5775 Pomona Street
6 Medicare tax withheld
$24,612.00
$356.87
7 Social security tips
8 Allocated tips
9 Advance EIC payment
10 Dependent care benefits
Your City, GA 30308
d Employee's social security number
895-00-9015
$1,200.00
e Employee's first name and initial
Last Name
Mary J.
Hood
Suff.
11 Nonqualified plans
12a See instructions for box 12
13 Check boxes
3717 E. Lee Street
Statutory
employee
Retirement
plan
14 Other
Your City, GA 30308
12b
Third-party
sick pay
12c
12d
f Employee's address and ZIP code
15 State Employer's state ID number 16 State wages, tips, etc.
YS
557-2315
$24,612.00
17 State income tax
18 Local wages, tips, etc.
$265.00
2006
19 Local income tax 20 Locality Name
Name: Troy H. McCook
DOB: 03/12/1933
SS#: 876-00-6251
Employment: Retired
Marital Status: Married
Spouse’s name (if any): Yvonne A. Smith
People who lived in the house with you and anyone living outside of your home that you
or your spouse (if any) supported during the tax year:
Name
Yvonne A. Smith
Ashley Fergus
SS#
DOB
853-00-2894 10/30/1938
867-00-7521 04/05/1993
Relationship
Spouse
Granddaughter
You and your wife, Yvonne, are both retired. You and your wife receive income from
pensions and social security. Your granddaughter moved in with you in May of 2005
and you provide all of her support. You and your family lived in the state of Georgia for
the entire year and are U.S. Citizens. Georgia has a state income tax.
fictitious data
CORRECTED (if checked)
PAYER'S name, street address, city, state, and ZIP code
1 Gross distribution
Defense Finance and Accounting Service
$
OMB No. 1545-0119
23,919
2008
2a Taxable amount
Distributions From Pensions,
Annuities, Retirement or ProfitSharing Plans, IRAs, Insurance
Contracts, etc.
Us Military Retirement Pay
23,919 Form 1099-R
$
P.O. Box 7139
2b Taxable amount
not determined
Your City, GA 30308
PAYER'S Federal identification
RECIPIENT'S identification 3 Capital gain (included
4 Federal income tax
number
number
in box 2a)
withheld
00-123456
876-00-6251
$
$
5 Employee contributions
or insurance premiums
6 Net unrealized
appreciation in
employer's securities
$
8 Other
RECIPIENT'S name
Troy McCook
$
Street Address (including apt. no)
7 Distribution IRA/
code(s)
30911 Bard Rd
1,580.00
SEP/
SIMPLE
$
City, state, and ZIP code
Your City, GA 30308
Account number (see instructions)
%
9a Your percentage of total
distribution
%
9b Total employee contributions
10 State tax withheld
11 State/Payer's state no.
$
YS 123456
This information is
being furnished to the
Internal Revenue
Service.
$
$
13 Local tax withheld
$
$
Form 1099-R
Copy B
Report this income
on your federal tax
return. If this form
shows federal
income tax withheld
in box 4, attach this
copy to your return.
Total
distribution
12 State distribution
$
$23,919
$
14 Name of locality
15 Local distribution
$
$
Department of the Treasury - Internal Revenue Service
Form SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT
• PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME.
• SEE THE REVERSE FOR MORE INFORMATION.
Box 1. Name
Box 2. Beneficiary's Social Security Number
2008
Yvonne A. Smith
853-00-2894
Box 3. Benefits Paid in 2005
Box 4. Benefits Repaid to SSA in 2005
Box 5. Net Benefits for 2004 (Box 3 minus Box 4)
$3,645.00
$3,645.00
DESCRIPTION OF AMOUNT IN BOX 3
DESCRIPTION OF AMOUNT IN BOX 4
Paid by check or direct
deposit: $3,333.00
.
Box 6. Voluntary Federal Income Tax Withholding
Medicare Premium deducted:
$312.00
Total:
Box 7. Address
30911 Bard Road
$3,645.00
Your City, GA 30308
Box 8. Claim Number (Use this number if you need to contact SSA.)
Form SSA-1099-SM
DO NOT RETURN THIS FORM TO SSA OR IRS
Form SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT
• PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME.
• SEE THE REVERSE FOR MORE INFORMATION.
Box 1. Name
Box 2. Beneficiary's Social Security Number
2008
Troy McCook
876-00-6251
Box 3. Benefits Paid in 2005
Box 4. Benefits Repaid to SSA in 2005
Box 5. Net Benefits for 2004 (Box 3 minus Box 4)
$12,675.00
$12,675.00
DESCRIPTION OF AMOUNT IN BOX 3
DESCRIPTION OF AMOUNT IN BOX 4
Paid by check or direct
deposit: $11,737.00
.
Box 6. Voluntary Federal Income Tax Withholding
Medicare Premium deducted:
$938.00
Total:
Box 7. Address
30911 Bard Road
$12,675.00
Your City, GA 30308
Box 8. Claim Number (Use this number if you need to contact SSA.)
Form SSA-1099-SM
DO NOT RETURN THIS FORM TO SSA OR IRS
| File Type | application/pdf |
| File Title | assistance study-Troy Mccook-2008.xls |
| Author | 0SBKB |
| File Modified | 2008-12-23 |
| File Created | 2008-12-10 |