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Wage and Income Transcript

Request Date: 02-23-2024
Response Date: 02-23-2024
Tracking Number: 105595412203

SSN Provided: 301-74-8062
Tax Period Requested: December, 2018

Form W-2 Wage and Tax Statement

Employer:

Employer Identification Number (EIN):466000364
STATE OF SOUTH DAKOTA
500 E CAPITOL AVE
PIERRE, SD 57501-5007

Employee:

Employee's Social Security Number: 301-74-8062
HUNTER B SUMMERS
5904 W TECUMSEH CT
SIOUX FALLS, SD 57106-0435

Submission Type:Original document
Wages, Tips and Other Compensation:$35,689.00
Federal Income Tax Withheld:$3,938.00
Social Security Wages:$39,806.00
Social Security Tax Withheld:$2,467.00
Medicare Wages and Tips:$39,806.00
Medicare Tax Withheld:$577.00
Social Security Tips:$0.00
Allocated Tips:$0.00
Dependent Care Benefits:$4,995.00
Deferred Compensation:$0.00
Code "Q" Nontaxable Combat Pay:$0.00
Code "W" Employer Contributions to a Health Savings Account:$1,200.00
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:$11,508.00
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 5498 SA

Trustee:

Trustee's Federal Identification Number (FIN):450283315
HEALTHCARE BANK A DIVISION OF BELL BANK
PO BOX 9184
FARGO, ND 58106-9184

Participant:

Participant's Identification Number: 301-74-8062
HUNTER SUMMERS
5904 W TECUMSEH CT
SIOUX FALLS, SD 57106-0435

Submission Type:Original document
Account Number (Optional):DBI27085301748062
MSA Contributions:$0.00
Current Contributions:$1,200.00
Future Contributions:$0.00
Rollover MSA Contributions:$0.00
MSA Fair Market Value:$101.00
HSA Indicator:HSA Box Checked
Archer MSA Indicator:Archer MSA Box Not Checked
MA MSA Indicator:Not Checked

Form 1099-SA or 5498-SA

Payer:

Payer's Federal Identification Number (FIN):450283315
HEALTHCARE BANK A DIVISION OF BELL BANK
PO BOX 9184
FARGO, ND 58106-9184

Recipient:

Recipient's Identification Number: 301-74-8062
HUNTER SUMMERS
5904 W TECUMSEH CT
SIOUX FALLS, SD 57106-0435

Submission Type:Original document
Account Number (Optional):DBI27085301748062
MSA Distribution Code:Normal Distribution
Earnings on Distributive Excess Contributions:$0.00
MSA Gross Distributions:$1,198.00
FMV On Date of Death:$0.00
HSA Indicator:HSA Box Checked
Archer MSA Indicator:Archer MSA Box Not Checked
MA MSA Indicator:Not Checked

This Product Contains Sensitive Taxpayer Data