SOI-329 - Website Usability Evaluation; SOI-331 - Multi-City Taxpayer Assistance Behavioral Study; SOI-332 - IRS SB/SE ESTATE and GIFT TAX CUSTOMERS

CORRECTED (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