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2ot4-2o15 Independent
C$dff,["n%%ol.on,o'.
Student Verifi cation Worksheet
Lo Plqtq' leonordtown Pflnce Frededck Woldorf
The College of Southern Maryland's Financial Assistance Department verifies all students who have been selected for
verification by the federal processor, or when conflicting information needs to be resolved. The verification process can
take up to 6 weeks from the time the student submits the final document needed to complete the verification.
l o
tq tr6
a29ot
q-tc.
aurf
Phone Number (include area code)
In the box below, list:
1. Yourself (and your spouse)
2. Your children, if you will provide more than half of their support between July 1, 2014 and June 30, 2015.
4. Other people, if they now live with you, you provide more than half of their support AND you will continue to provide
more than half of their support between July 1, 2014 and June 30, 2015.
( ) _
ettena
lf more than twelve are in the submit additional information and student lD on the
Name of College
(lf aplicable)
WIII be Enrolled
atLeast Half
Ti me@adegreeor
e+e+er o<JOl 3\
Student lD
,il_,_]3_ l. As of the date you originally signed your FAFSA, whatwas the total in cash,
savings and checking acounts.
2. As of the date you originally signed your FAFSA, what was the net worth of
your investments, induding real estate (Do not include the value of the home you reside in)?
Net worth means cunent value minus debt
3. As of the date you originally signed your FAFSA" what uras the net worth of
your or your spouse's cunent businesses and/or
investment farms?
c
o
I
fnru" attest I have not and am not requircd to file taxes for 2013
Spouse Signature
(Optional)
Date: fl tfl tq
, l
ffi
fnn" have filed taxes. (2013 IRS issued tax return transcript required OR unchanged IRS Data RetrievalTool used)
l_l
nrue will file taxes and will submit either a 2013 IRS issued tax return transcript OR use the IRS Data RetrievalTool
(if eiigible) that is part of the FAFSA on the Web at FAFSA.gov and make no changes to the information.
Did you work at any time in 20'13?
-/
Yes (submitcopies of ALLW-2'sfor2013)
No (l did not work at any time in 2013)
By signing this worksheet, I certify that all the information rcported on this worksheet is complete and correct. I
further understand
Studenfs Signature
(Required)
doeumentation may be rcquircd in orderto complete veriftcation.
Date:
WARNING: lf you purposetully give false or misleading information on this
worksheet, vou may be fined up to $20,000, be sentenced to iail, or both.
Send All Gorreopondence to:
College of Southem Maryland " Financial Assistance Department
P.O. Box 910
*
La Plata. MD 2(n|6
"
Fax 301-93t1-789t1
Telephone: 301-9*2251,30170.3008, 301S84S131, erd. 7531, or 301-93+7531 (Direct Line)
EMPTOYEE W.2 WAGE SUMMARY 2013
gogit-loarExl1
1xnqn
The ctart below indicates your 2013 voluntary payroll adiustments
which are incltded {+}, orcluded {-}, or did not affcct {?t/A}
your foderal
BRENNAN TITLE CORPORATION
wages {Box 1} and state wages.
3481 OLOWASHINGTON RO
SUITE ilXO
WALDORFMD206O2
YltLUlUIAnYflrJllSItlEItIS YTDAHO|rI{I FE0CBATWAGES ll0WAeES
PREIXHITH nS
-6Am -$.S
FEoEnAtwrrilHotlttcEreflFTtofls S 2
rDwnlrH0lDttrcExEilFlrolrs s 1
REGI'I.ARWAGES FOBzOI3 EZE.M
BFITTNEY C THOMA$SE
11602 BARD|TTOOR
gT
WALDORFMO20602
14003
PAYRoI-IsBY PAYCTIEX'
Copy C, fur employees records
Th[si nl ormafMi sbei rufmi stg| t0thherna| fevenugsni ce.l fyNafe' eq,,i edbfeata(refm,argtgencepertdty0' 0tErs$cl i 0r| mayi mdmr
Copy B, to be filed with employees FEDEML tax retum
Form W-2 Wage and Tax Statement 2013
Form W-2 Wage and Tax Statement 2013
oo32- 1o3oExt 1
I
voro
n n n n n n n r < t - n n ^ o n n I
tmpl oynrs [ame, aodrtss, and zl P c00e
BRENT{AN 1ITLE CORPORA?ION
3261 OLD WASEINGTON RD
sur f E 3040
wAr.DoRE MD 20602
Dopartment of the Trasury
-
lnlernal Fevenue Service
oMB t{0. 1545-0008
5 2 - 1 7 4 9 2 4 2 I z L A- 3 7 - 2 1 7 7
,[ps,@swpeoru
6 1 8 6 . 0 0
I Fsdenl in$trp ta( wilhhdd
5 0 5 . 6 0
empEYee
rxru-y.
Dhn siek tay
uooal secunly v{ages
6 186. 00 3 8 3 , 5 3
t 4 ul net r tmptoyee' s nam, adoress, ano l l P code
BRITTNEY C TI{OMASSET
11602 8AX.DM00R CT
WALDORF I,'D 20602
Meol care wages ang l tps
6 186. 00 a9 - 70
Social security tips I Allocated tips
, Advance EIC payment 0 uegcndeil caro benelds
I nonquailile0 plans
l5 $tate
MD
Employer's state lD No.
o6337236
t6 Slate waoes, tips, elc.
6186. 00
1 7 $tale income tax
3 8 0 . 7 8
18 Local wages, tips, elc
'19
Local income tax 20 Locality name
r Gontrol number
0032_10308X11
I
Voi d
0000000251- oo0900 |
: Employels name, address, and ZIP code
BRENNAN TTTI,E COR?ORATTON
3261 OLD WASEINSTOI{ RD
surTB 3040
WALDORF MD 24602
Deparl ment ol the Treasury
-
l nternal Revenue Servi ce
0MB l tl o, 1545-0008
Dl,r{bcrgfilicdmnwlbs
ld
ttrtployeess@blwdymflts
5 2 - 1 7 4 9 2 8 2 I 2 r 8 - 3 r - 2 1 7 7
, xps, mff cotrpEnsu
6 1 8 6 , O 0
Z l-ederal rncorne hx wltrhdd
5 0 5 . 6 0
empoyee
pnn sic* 0oy
socral secuflly lYages
6 1 8 6 . 0 0
SECUUty KX WIItrflEIU
3 8 3 . 5 3
l 2 see l nstrs. l or tsox 1
' 14
ol her I Empl oyee' s name, address, and ZIP code
BRTTTNEY C TEOI'TASSET
11602 BAT'MOOR CT
}'ALDORF UD 20602
) Medl care wages and tl ps
6 1 8 6 . 0 0
ti Meorcare lax wrtnheld
8 9 - 7 A
'
Soci al securi ty ti ps I Allocated t,ps
Advdnc EIC payment u ue0enoem carc oenenrs
ilonqua[ned plans
15 Shte
UD
Employer's slate lD ilo.
06337236
l6 Stale sages, tips, etc.
6 1 8 6 . 0 0
7 Stale incom8 tax
3 8 0 . 7 8
l8 Local wages, tips, etc- 1
g
Local income bx 20 Loaality name
Thbi ddmal i mbbei mtuml $edt0thehl eml 8ssuSdvbe. l fvfl mrmui rcdt0fl eati l retum.eMl beremd$trol h*s*f,l i i l mavbi mmsedmwi fthhi nmmei stadl esndwfdl torewti l
.;i.if
l
iifi, i . ]
,.,,li i
.
1,
ii
,'il'
i"*
' . , ]
' geg.
oo,
lf,nqia:i$^
*S"d.ng
i a. 3+,
i zg. o1
OePt'
ot tne Treasury
-
IRS
Form 1099-R
:
y,'li
i lii
jf
'
t 6'fi ri':'i'dbW
suNTRUsr
BANKS rr, rc 4oi "i i i l "'
l : 9, . l ox
coss MAr I coDe' r i osa
ATLANTA
GA 30302
865-855-5738
90. 42
1 cross distribution--
OMB No. 1545- 01 19
2@13
Form 1099-R
Di stri buti ons
From
Pensi ons,
Annui ti es,
Reti rement
or
Profi t-Shari nq
Ptans. tRAsI
Insurance
Contracts,
etc.
2a Taxabl e amount
90. 42
zo t axabt e amount
l ot al
not determi ned
di stri buti on
PAYEFT' S federat i denti f i ci Gnl i moer
59- 3482855
0801
R E C I P I E N T'S identif icatiom u m be r-
xxx-xx-"L77
In box 2a)
4 Federal income tax wittrneta-
18. 08
5 Employee contibutions
-
/Designated Roth confibutions or
I nsur ance pTemt ums
fiiii*lFXnF,lHffiril
5 Net unreal i zed appreci ati on
rn emptoyefs securi ti es
7 Di stri buti on code(s)
I
SI I VPLE
9a Your percentage
of totit d[iiibr-ibu,on
9b Total empl oyee contri buti oni
o*"ti'tfig?$ufi_tiboo
1 1 1 st year of desi g. Fl oth conti i b
13 State/Payels state no.
I 0603166--
14 State di stri buti on
E
E
- - - - - - - - - 9U. qZ
r.opy tt
Rporl l hi s i ncome 0n your l ederal l ax rel urn. t t t ht s l 0rm
sn0ws t ederat i ncome l ax wi t hhet d i n box 4, ai l ach I hi s
f,llil,1i.ffi litll;,lj's
jntomarion
is beins rurnished
10 Amount al l ocabl e to IRB wl thj n 5 years
16 Name of l ocal i t y
17 Locat di stri buti on
t
www.trs.gov/form 1 099r
L347L47L
t s47r 47t
t347 L47 L
Department
of the Treasury -
Internal R"u"nue SurVG
From
rities,
)nt or
Depanment of the treasury -
161g;;;;;;E;;il
Form 1099-R
cnFtptra
855
- 855- 5758
ffi
+ HU
iT
tfn #:'r Hfr :q fl
rft'dnp, r-r4mrc'
*"
itfli*?g*uf
.3;=Ulri
cooe
"riose
I Gross distribution
98. 42
","e'ji:"
Distributions
From
Pensions,
Annuities.
Retirement
oi
Profit-sharino
Plans, lRAs]
Insurance
Contracts,
etc.
2a Taxabte amount
; 90, 42
2b Taxable amounl
----T"td-
not detemined
distribution
PAYER'S federat identificailon num6el
59-348?835
0801
FECIPIENT' S i denti fi catton numG
xxx-xx-2t77
uaprra gatn (rnctudect
in box 2a)
4 Federal income ta witnnelO-
; 18. 08
5 erptoyge contioutioro-
/Estgnated Roth dnfibutjon, or
rnSUran@ premiufts
fl ii I i I P hililH'ilg
d $lFlmn
il'ins il s a'le' cen'lry' and z P or ro'asn
om'lalii'
i n mpl oy6r' s
$curi l i es
I
code(s) IHA"/
SEF/
IIMPLE
8 Other
ea Your percsr:se
or totar oisGour6i--
9b Totat emptoyee contriturili!
t2 State tax withhetd
t3 State/Payer's state no.
roeoai ee
--
'riii'ilB?iii?"Lfitoo
1 1sl year of desig. Roth conkib.
__- - - - - - 90: 42 vopy z
File this copy with your state, city, or
l ocal i ncome tax rel urn. when requi red.
10 Amount ailocabte to tnnGtninTl;E
@
:'i:l:::::i___l
17 Ltral distribution
l - - - - - - - - -
Form 1099-R
PAY- EBSnamest r eet addr ess, ci l yor t oWn, p' oui n. " o, @
l !.| !!IE!l rI
BANK rAc RETTREMENT
stR.
SUNTRUST
BANKS I NC 4Oi " i i i ' ' ' '
l : g: . . ! gx
46s5 t 4ArL coue-i i 6t s
ATLANTA GA 50502
865
- 855- 5738
'I
Gross distribution
90. 42
OMB No. 1545- 01 19
2@13
Form 1099-R
Di stri buti ons
From
Pensi ons,
Annui ti es.
Reti rement
oi
Profi t-Shari nq
Ptans, l RAs]
Insurance
Contracts,
etc.
2a Taxabl e amount
90. 42
zo I axabl e amount
Tot al
not det ermi ned
di st ri but i on
PAYEB' S federat i Oenti fi cati on nui l Oer
59-3482833
0801
xxx-xx-2L77
uapt rat gat n (t ncl uded
i n box 2a)
4 Federal i ncome t a" wi t hhel d-
; 18. 08
C Empl oyee Conl f l but i ons
/Designated Foth confibutjons ol
I nsur ance pr emi ums
RECIPIENTS name. slreel adOr"r fr,l,
illll'FX*8'68R'Eor*,
WALDORF
MD TO6OZ
6 Net unreal i zed appreci ati on
i n empl oyer' s securi ti es
code(s)
1
I RA/
SI MPLE
8 Other
va your percentage
ol total di stri bunon
9b Total empl oyee contri buti ons
^*""[iTilg?4iifi[%oo' 11
1st year of desi g. Fi oth contri b.
13 State/Payer's state no.
MD
I05-08-16-6
- -
' 14
State di stri buti on
I
t - - - - - - - - - 9U: 42
uopy c
For Recipient' s
Records
I nts tntormati on i s bernq furni shed to
the l nternal Revenue Seryi ce.
10 Amount al l ocabl e to IRR wi l hi n 5 years
15 Local tax wi thhel d
ro t \ drne oI t ocal t l y
17 Local di stri buti on
D
: - - - - - - - -
www.i rs. gov/form1
09gr
(keep for your records) Department
of the Treasury -
Internal Reu"nre S"rG
c Employe/s
AEROTEK
name, addre$, dd z|P @de I
Z. S@ itrstudims for box 12
l $
Wags, tips, oth6r ompenslioh
878.50
2 Fedel in@me tax withhetd-
57.97
12b
t $
3 Social writy wgs
878.50
,l S@ialwrity tax withheld
54.47
730,I PARKWAY DR
HANOVER, MD 21076
e ficl
l2c
a
l-c
t s
5 lrediqe wag6 ad tips
878.50
6 Medi@c tar withheld
12. 74
Sufi-
7 S@ial sdrity tips
8 Ail@ated tips
BRITTNEY C THOMASSET
11602 BARDMOOR COURT
WALDORF, MD 20602
2e
t $
hport Code: PRTP4yTI
9
It Nequalified plars
t0 Dependst @E bselits
h6 hlmdim Ebmqhished totu
nrmdRevfre WF
13 urulry RdffiEr--T#a
mruy*
dan shk !
n[ - l r - Copy B To Be Filed With
Employee's FEDERAL
Tax Retum
' l 4 o f i * %
I
- - +
l Empto!@'s sjd serunty n tnt
21&31-2177
I 5 Sbre
I
Ehploye/s $ale lD numb*
MD
I o687ss3o
$aie mg6, tip6, dc
878_50
17 Sate i@me tax
51. 91
18 Locd Eges, tips, etc.
B To Be Fited With Emptov;E
ffi
s2-1822806
AEROTEK
12.
l q
r wag6, tips, o&tsmpenstiq
878.50
Z Fedel in@me tax withheld
57.97
730.I PARKWAY DR
HANOVER, MD 21076
-
e Emp@ye s rd mre and inilial
Last name
1 o f 1
BRITTNEY C THOMASSET
,I1602
BARDMOOR COURT
WALDORF, MD 20602
2b
l $
3 Sftid *flrity wag6
878.50
4 Social setufty tax witntrEta-
54.47
12c
i$
l s
12d
5 Medire kgs and tjF
878.50
6 Medlde tax withhetd
12.74
I S@ial esrity tipi
5 AMed tips
l2e
9
l{ Nonqualifed
olans
t0 Depondont re bnefits
Copy 2 To Be Filed With
Employee's STATE, ClTy or
LOCAL Income Tax Retum
mFoyee
Sn d dv
'
Olher
I 5 State
MD
lmport Code: PRTp4yTf
Employee's wid srority numG
218-31-2177
Emptoyers $ate lD number
06875530
Ste wagreq tips, ei*
* _ _
glB.so
17$aieln(Metax
1tf
fcEa|mge;?;ffi
51. 91 |
W-2 Wage and Tax Statement 201 S.Rejssued
AEROTEK
2z
l $
tjp6, oths @pqsation
878.50
? Fod6al intMe l,ar wilhheld
57.97
7301 PARKWAY DR
HANOVFR N, | N ' 1N'
zb
t $
3 S@ials@rityMgs
878.50
4 Smialseority cx rvit-heE-
54.47
2c
t $
5 Medire wag and lips
878"50
6 Medicare tax wifhhdd
12.74
e Employee s fict nam. rna initiA
2d
l $
7 Sociel ssuritytips
t tips
1 o f
BRITTNEY C THOMASSET
11602 BARDMOOR COURT
WALDORF, MD 20602
2e
I
l0 Oependent E benefts
11 Ndnuagfiod Dlans
13
s,ylry nermo
---Tiro-fr
ry. ds $ddv-
n T-l rr' Copy 2 To Be Filed With
Employee's STATE, CIW or
LOC/{- Income Tax Retum
l4 Oher
lmport Code: PR7p4y.ff
t Employee's $cial s6drity h
218-31-2177
I 5 State
MD
Employe/s sbte lD number
06875530
l7 Sate in@ rax
lt-
LmiGles, !ps, etc.
51.91 |
878.50
20 Loelity name
W-2 Wage and Tax Statment 201
gRei$ued
ibtemenl
T@sury-lntmal Revenue Seryi@ OMB # 154+0008 Copt 2 To Be Filed With Employe,s State, Clry or L@l Tax DeDartments
I.=""J-!t
j1 R:y'lsag
_oIBj
lysoooe_ c"py z@
Departments
J
c Emdc
AERO
52-1822ffi6
| 2a Se instruaims fo box 1
l s
I Wag6, tips, gther
@mpensaiion
878.50 rEK
57.97
7301 PARKWAY DR
HANOVER, MD21076
-
e Employe s fi Et nam" ana initaG
1 o f 1
BRITTNEY C THOMASSET
11602 BARDMOOR
COURT
WALDORF, MD 20602
lmport Code: PRTp4yTt
b
l $
3scidwritywage
-
878.50
a Socid s@.ity tax wihheld
54.47
l2c
l $
t2d
5 MediE wag6 and 6As
878.50
6 Medire trax withhdd
12. 74
TSsidwritytiF
I Atlffird 0p
2e
t e t0 Dependenl @@ benefits
i n6 hmM 6bDq tun#d bh hhd
|M,aqrq@Fd!
orituffi n@
ffril?S*d
prhs hctre,s raa& d yi{
11 Norqualified plans
;ffiH
fl f-r
r vv! v I vt Lt vt r l vI r : l
IECORDS. (See Notjce to
:mdovee on trac*-l
14 Olhd
20L@litynre
t erdote's*"iawrity*G
2.18-31_2177
T :,". |
.:*l"j^"^"ra reffi
wr u- Ur o! 1c c r l u
|
___81850
t7 S'tate in@me lax
I
f S foet wages, tps,;d-
51. 91 |
Fom W-2 Wage and Tax Sbtement 2013 -
Reissued
oMB #
.1545-0008
Copy C for Employee's Re@rds
li3iJll"'ffi
Employee Reference Copy
YV.-,?.",."""":3!;"#1'* ?pl._3""""
d Control number
0000088106 v5c
Dept.
| 50002
Corp.
J
Employef use only
VVs I A A516A
Employe/s name, address, and Zlp cod6
PNC BANK NA
4100 w
't50TH
sT B7-Y832-02-1
CLEVELAND, OH 44135
e/f Employee's name, addreaa, and ZIP cods
BRITTNEY C THOMASSET
11602 BARDMOOR COURT
WALDORF, MD 20602
Employers FEO lO numbr
22-1146430
a Employee'3 SSA number
218-31-2177
I wagea, tipa, other comp.
a4' f 4 i t
2 Federal income tax withhsld
l nt nn
3 Social security wages
4175.42
4 Social Eecuilty tax withheld
258.88
Medicarc wages and tipa
L,l'r1 at
Medicare tax withheld
AN
Social security tipa AIOCated tips
l0 Depondont caro benefits
l r Nonqual i f i ed pl ana lza Seeinstuctions for box 12
DDr 3-72
14 Other
l2c
t2d
13 Sht empl Ret. plan|3rd party sick pa,
'15
State lEmployeds stato lD no
MD I 0677990 8
6 State wagss, tip6, otc.
417 1 i t
17 Stat6 income tax 8 Local wages, tips, stc-
19 Local i ncomet ax
l0 Locality namo
2013 W-2 and EARNTNGS SUMMARY
Thi s- sur mar y sect i on i s i ncl uded wi t h your l l - 2 t o hel p descr i be t hl s
port l on i n more det ai l . The reverse si de I ncl udes genl ral
i nf ormat l on t hat
{: l
t 11{
l l _: 9
f i nd hel pf ul . The f ol l owt ng ref l ect s
}our
f i nal pay st ut , -pi us
any adJustments made by your employer.
GRoSS
pAy
4,175-.42 socIAL sEcuRITy 258.88
FED. I]ICOME
TAX WITHHELD
Box 02 0F }' |-2
STATE IIICOME TAX
Box 17 0F }t-2
TOCAL IIICOME TAX
Box t9 0F l.|-2
6 2011 ADP. t NC
BRITTNEY C THOMASSET
11602 BARDMOOR COURT
WALDORF, MD 20602
402. 00
273.53
0. 00
TAX WITHHETD
Box 04 0F ll-2
MEDICARE TAX
}{ITHHEID
Box 06 0F t f -2
SUI / SDI
Box 14 0F l,l-2
60. 54
0. 00
Social Security Numbor 218-31-2177
Taxable Marital Statua:
SINGLE
Exomptions,/Allowances:
Foder al : 2
Stat6i 1
Local: 0
To change your empl oyee W-4 prof i l e i nf ormat l on
f i l e a new W-4 wi t h your-payrol l depart ment
PAGE 01 OF 01
wages, tlps, other comp.
4175.42
2 FsdeEl income tax withhold
402.00
3 Social Eocurity wagos
4175.42
4 Social security tax withheld
258.88
5 Medicaro wagss and tips
4175.42
6 Modi caretaxwi thhetd
60.54
d Control number
0000088106 vsc
Dept.
150002
CoO.
I
Employer use only
LWs I A 65156
c Employsr's name, address, and Zlp codo
PNC BANK NA
4100 w 150TH ST B7-Y832-O2-1
CLEVELAND, OH 44135
Empl oyer' s FED l D numbet
22-11L6Aan
yuc s 0oA numol
21431-2't77
7 Social Eocurity tips U Ailocated tipa
9: l0 Dependontcare bonofits
I Nonqualified plans
2a See instructions for box 12
DDI 3.72
14 Other
26
lJ Stat emplRt. plan prd pady sick pay
e/f Employee'a name, address and Zlp codo
BRITTNEY C THOMASSET
,I1602
BARDMOOR COURT
WALDORF, MD 20602
15 Stat
MD
Employeds state lD no
0677990 8
6 State wagea, tipa, etc.
4175.42
17 Stato i ncometax
273.53
l8 Local wages, tips, etc,
19 Local i ncomstax 20 Locality nams
Federal Fi l i ng Copy
w-2
*3?;"#1 '"-
?"pJS"..,
1 Wages, tips, other comp.
4175.42
2 Foderal income tax withheld
402.00
3 Social socurity wagos
4175.42
4 social socurity t"iHd,Hf'o
5 Medicare wages and tips
4175.42
6 Medicare tax withheld
60.54
d Control number
0000088106 v5c
Dept,
t50002
Corp.
I
Employer use only
LWs I A 6515e
c Employe/s nams, addrsss, and Zlp codo
PNC BANK NA
4100 w 150TH ST B7-YB32-02-I
CLEVELAND, OH 44135
ErrProyar s rEu t u nl
22-1146430
t Employee's SSA number
218-31-2177
Social security tips Allocatod tips
| , ' , : . . ' ' : : : ' . , j : ' . . : ' : : : : : : . , , ' , ' ' . : . : i
0 Dopendentcare benefits
I Nonqualitied plans lza
3.72 DDI
14 Other a0
J Stat emplRet. planl3rd party sick pa,
o/f Employoo's name, addross and Zlp
BRITTNEY C THOMASSET
11602 BARDMOOR COURT
WALDORF, MD 20602
code
:mployCs state lD no
0677990 I
15 Stat(
MD
16 State wagos, tips, etc.
4175.42
17 State i ncometax
273.53
18 Local wages, tipa, etc.
19 Locat ancomot ax ItJ Localty namo
MD. State Fiting Copy
W-2
*3?"","#1 '"'
?.0'!.3"""
Wages, tips, other comp.
4175.42
2 Federal income tax withheld
402.00
3 Social security wa?es42 4 Social socurity tax withheld
258.88
5 Medicare wages and tips
4175.42
Medicare tax withheld
60.54
t Control number I Deot.
0000088106 vsc bsoooz
Corp.
I
Employer use only
LWs
I A 6515G
c Employer's namo, address, and Zlp code
PNC BANK NA
4100 w 150TH ST B7-Y832-02-1
CLEVELAND, OH 44135
Employe/s FED lD r
22-1146430
a Emptoyee' s ssA numbor
21a31-2177
7 Social security tips 8 Allocatod tips
0 Dependent cars bsnefits
l l Nonqual i f i ed pl ans
DDI 3. 72
14 Other tzo
t zc
J Stal 6mp]Ret. ptanl3rd pafry srck pa
o/f Employec's name, addrsss and Ztp csle
BRITTNEY C THOMASSET
I,1602 BARDMOOR COURT
WALDORF, MD 20602
15 Stat(
MD
Employe/s state lD no
0677990 8
16 State wagea, tips, otc.
4175.42
17 State incometax
273.53
18 Local waggs, t i ps, et c.
l 9 Locat ancomet ax lO Locality namo
Ci ty or Local Fi l i ng Copy
-2
*3?;"#1 0"'
2013
ffi Internal RevEnuE S ervice
arrer"
United States Department af the rreaiury
Thi s Product Contai ns Sensi ti ve Taxpayer Data
Request Dat e : 05- l - 8- 201- 4
Response Dat e: 05- L8- 2014
Tr acki ng Number : 100197393711
Tax Return Transcri Dt
SSN Pr ovi dedz 2r a- 3r - 2I 77
Tax Per i - od Endi ng: Dec. 3L, 2013
The fol l owi ng i l ems refl ect the amount as shown on the return (pR), and
the amount as adj usted (PC), i f appl i cabl e. They do not shor^r aubsequent
acti wi -trr on the account.
SSN:
SPOUSE SSN:
NAME(S) SHOWN ON RETURN: BRITTNEY C THOMASSET
ADDRESS: L1502 BARDMOOR CT
WALDORF, I VI D 20602- 31- 03- 021
FILING STATUS:
FORM NIJMBER:
CYCLE POSTED:
RECEIVED DATE:
REMITTA\ICE:
EXEMPTION NTIMBER:
DEPENDEM| ]- NAME CTRI:
DEPENDENT 1 SSN:
DEPENDEIfT 2 NAME CTRL:
DEPENDE}{I 2 SSN:
DEPENDENT 3 NAME CTRL:
DEPENDENT 3 SSN:
DEPENDENT 4 NAME CTRL:
DEPENDENT 4 SSN:
IDENTITY THEFT PERSONAL fD NUMBER:
PTI N:
PREPARER EIN:
Income
z 1 6 - 5 r - z t I I
Si ngl e
1 0 4 0
20140504
A p r . L 5 . 2 0 1 4
$o. oo
1
0 0 0 0 0 0
WAGES, SALARI ES, TI PS, ETC: . f i 1, 6, 377. 00
TAXABL E I NTEREST I NCOME: SCH B: . . . . . . 3 0 . 0 0
TAX- EXEMPT I NTEREST: . . . . S0. 00
ORDI NARY Df VI DEND I NCOME: SCH B: . . . 50. 00
QUALI FI ED DI VTDENDS: . . g0. 00
REFLI NDS OF STATE/ LOCAI TAXES: . . 50. 00
AL I MONY RECEI VED: . . . . . . 9 0 . 0 0
BUSI NESS I NCOME OR I OSS ( Schedul e C) : . . . . $0. 00
BUSI NESS I NCOME OR LOSS: SCH C PER COMPUTER: . . . 90. 00
CAPI TAI GAI N OR L OSS: ( Sc h e d u l e
D) : . . . . . . . 9 0 . 0 0
CAPI TAL GAI NS OR LOSS: SCH D PER COMPI I TER: . . . . . . S0. 00
OT HE R GA I NS OR L OS S E S ( F o r n 4 7 9 7 ) : . . . . . . . . . 5 0 . 0 0
TOTA! I RA DI STRI BI I TI ONS: . . . . . . . $ 0 . 0 0
TAXABLE I RA DI STRI BI I TI ONS: . . 50. 00
TOTAL PENSI ONS AND ANNUI TI ES: . i o. oo
TAXABLE PENSI ON/ ANNUI TY AMOUNT: . . S270. 00
RENT/ ROYALTY/ PARn{ ERSH] P/ ESTATE ( Schedut _e E) : . . . . 50. 00
RENT/RoYALTY/PARTNERSHIP/ESTATE (schedul e
E)
pER
CoMpIITER: ...50.00
RENT/ ROyAr , Tr y TNCOME/ LOSS
pER
COMPUTER: . . . . . 50. 00
ESTATE/ TRUST I NCOME/ LOSS
pER
COMpTTTER: . . . . 90. 00
PARTNERSHI P/ S. CORP I NCOME/ I OSS PER COMPUTER: . . . . . $O. OO
FARM I NCOME OR LOSS ( Schedu1e F) : . . . . 90. 00
FARM I NCOME OR LOSS ( Schedul e F) PER COMPI I TER: . . . 50. 00
UNEMPt OYMnf r f COMPENSATI ON: . . . . . . 91, 143. 00
TOTAI SOCI AL SECURI TY BENEFI TS: . . . . . S0. 00
TAXABLE SOCI AI , SECURI TY BENEFI TS: . . . . S0. 00
TAXABLE SOCI AL SECURI TY BENEFI TS PER COMPUTER: . . . . . . . . . S0. 00
OT ] I { E R I NCOME : . . . . . . . . . S 8 5 6 . 0 0
SCHEDI I LE EI C SE I NCOME PER COMPUTER: . . . . . . . S0. 00
SCI { EDULE EI C EARNED I NCOME PER COMPUTER: . - - - . . . . S0. 00
SCH EI C DI SQUAL I FI ED I NC COMPUTER: . . . . . . . . g 0 . 0 0
T OT A L I NCOME : . - . . . . . 9 1 8 , 5 4 6 . 0 0
TOTAT, TNCOME PER COMPI I PER: . . . .
$18, 546. 00
Adj ustments to Income
EDUCATOR EXPENSES: . 50. 00
EDUCATOR EXPENSES PER COMPI I | ER: - . . . . . $0. 00
RESERVI ST AND OTHER BUSI NESS EXPENSE: . . . . . . $0. 00
HEALTH SAVI NGS ACCT DEDUCTI ON: . .
. . . . . g0. 00
HEALTH SAVINGS AccT DEDUCTTON
pER
COMpTR:
.$O.OO
MOV T NG E X P E NS E S : F 3 9 0 3 :
. . . . . 9 0 . 0 0
SELF EMPLOYMENT TAX DEDUCTI ON:
. . . . . g0. 00
SEI JF EMPI JOYMENT TAX DEDUCTI ON
pER
COMPI I TER: . . . .
. . $0. 00
KEOGH/ SEP CONTRI BUTI ON DEDUCTI ON:
. $O. OO
SELF- EMP HEALT' I I I NS DEDUCTI ON: . . .
. $0. 00
EARI Y Wf THDRAWAL OF SAVI NGS PENAI , Ty:
. . . . . . $0. 00
A],IMONY PAID SSN:
AL I MONY PAI D: .
. . g 0 . 0 0
I RA DE DUCT I ON: . . -
. . . . 9 0 . 0 0
I RA DEDUCTI ON PER COMPI I TER:
. . 90. 00
STUDENT L OAN I NTEREST DEDUCTI ON: - . . . .
. . . . . 5 0 . 0 0
STUDENT LOAN I NTEREST DEDUCTI ON
pER
COMPUTER: . . . .
. . . . . . $0. 00
TUI TI ON AND FEES DEDUCTI ON:
. . . . 90. 00
TUTTI ON AND FEES DEDUCTI ON pER
COMPI TTER: . . . .
. . . . . g0. 00
, JURY DI J| Y PAY DEDUCTTON: . . .
. . $0. 00
DOMESTI C PRODUCTI ON ACTI VI TI ES DEDUCTI ON:
. $0. 00
OTHER ADJ USTMENTS:
. . . . . $ 0 . 0 0
ARCHER MSA DEDUCTI ON: . . .
. . . $ 0 . 0 0
ARCHER MSA DEDUCTIoN PER COMpUTER:
.$O.OO
TOTAI AD, J USTMENTS] . . . . .
. $ O. o O
TOTAL AD, J USTMENTS PER COMPI I 1 | ER: . . . .
. . . . . . g 0 . 0 0
A DWS T E D GROS S I Nc o ME : . . . .
. . . . . $ 1 8 , 6 4 6 . 0 0
AD, JUSTED GROSS I NCOME PER COMPTI TER: . . .
. . . . 519, 645. 00
Tax and Credi ts
6 5 - OR- OV E R:
. . . . . . . . NO
B L f ND:
. . . . . No
S P OUS E 6 5 - OR- OV E R:
. . . . . . NO
S P OUS E B T I ND:
. . . . . . . NO
STANDARD DEDUCTION PER COMPUIER: . . . .
$6, 100. OO
ADDI TI ONAI , STANDARD DEDUCTI ON
pER
COMPI JTER: . . . -
. . . . . $0. 00
TAX TABLE I NCOME
pER
COMpl r r ER: . . . .
. . 912, 5A6. 00
EXEMPTI ON AMOUNT
p ER
COMPUTER: . . . .
. . . . +: . g o o . o o
TAXABL E I NCOME:
. . . $ e , e +e . OO
TAXABLE f NCOME PER COMPI I | ER: . . . .
$e, eae. OO
TOTATJ POSTTI VE TNCOME
p ER
COMPUTER: . . . .
. . . . . Si e , 5 4 6 . 0 0
T E NT A T I V E T A X : . .
. . . . . 5 9 6 3 . 0 0
TENTATTVE TAX PER COMPUTER:
g853.00
FORM 881-4 ADDITTONAL TAX AMOUNT:
. . . $0. OO
TAX ON I NCOME LESS SOC SEC I NCOME
pER
COMPI I f ER: . . . .
. $0. 00
FORM 6 2 5 1 AL TERNATI VE MI NI MUM TAX: . .
. . . . . $ 0 . 0 0
FORM 6251 AITERNATIVE MINIMLM TAX
pER
COMpIJTER:
..$0.00
FOREI GN TAX CREDI T:
. . . g0. 00
FOREI GN TAX CREDI T PER COMPU: [ ER: . . . .
. . . . . . S0 . 0 0
FOREI GN I NCOI { E EXCLUSI ON
pER
COMP{ I | ER: . . . .
. . . . $0. 00
FOREI GN I NCOME EXCLUSI ON TAX PER COMpI I | ER:
. . . . . . $0. 00
CHr L D & DEPENDENT CARE CREDTT: . . . . .
. . $ 0 . 0 0
CHI LD & DEPENDENT CARE CREDI T
pER
COMPUTER: . . . .
. . $O. OO
CREDI T FOR EL DERL Y AND DI SABL ED: . . . .
. . . . $ 0 . 0 0
CREDI T FOR EL DERL Y AND DI SABL ED
p ER
COMPI I TER: . . .
. . . . . . $ 0 . 0 0
E DUCA T T ON CRE DI T :
. . . . . . 9 0 . 0 0
EDUCATI ON CREDI T PER COMPI I TER: . . . .
. . . 90. 00
GROSS EDUCATI ON CREDTT PER COMPI I TER: . . . .
. . . $0. 00
RETI REMEN| SAVI NGS CMTRB CREDI T: . . . .
. . . . $0. 00
RETI REMEMT SAVI NGS CNTRB CREDI T
pER
COMPI I | ER: . . .
. . . . , g0. 00
PRI M RET SAV CNTRB: F8 8 8 0 L NGA:
. . . . . $ 0 . 0 0
SEC RET SAV CNTRB: F8880 LN6B:
. $O. Oo
TOTAI RETf REMEN| SAVI NGS CONTRI BI I TI ON: F8BB0 CMpTR:
. . $0. 00
RESI DENTI AL ENERGY CREDI T:
. . . . $0. 00
RESI DENTI AI , ENERGY CREDI T PER COMPI I | ER: . . . .
. . . . . . g0. 00
CHI LD TAX CREDI T:
. S0. 00
CHI L D TAX CREDI T PER COMPUTER: . . . .
. . . $ 0 . 0 0
A DOP T I ON CRE DI T : F 8 8 3 9 :
. . . . . . $ 0 . 0 0
ADOPTI ON CREDI T PER COMPI I | ER: . . . .
. . . . 5 0 . 0 0
FORM 8839 REFUND ADOPTI ON CREDI T AMOUNT:
. . g0. 00
DC LST TI ME HOMEBI I YERS CREDI T:
. . . .
g0. 00
DC L5T TIME HOMEBUYERS CREDIT
pER
COMprrrER: . . . .
. . $0.00
FORM 8396 MORTGAGE CERTIFICATE CREDIT:
. . . . F0.00
FORM 8396 MORTGAGE CERTI FI CATE CREDI T
pER
COMPI I TER: . . . .
. . . . . . g0. 00
F3800, F8801 AND OTTTER CREDI T AMOUNT:
. . . . . $0. 00
FORM 3800 GENERAL BUSI NESS CREDI TS:
. $0. 00
FORM 3800 GENERAL BUSINESS CREDITS
pER
COMPIITER: . . . . .
$0.00
PRI OR YR Mf N TAX CREDI T: F8 8 0 j - :
. . . . . 9 0 . 0 0
PRI OR YR MI N TAx CREDI T: F8801 PER CoMPLI I | ER:
. . . . * o. oo
F8834 ELECTRI C VEHI CI JE CREDI T AMOI I NT:
. . . . $0. 00
F8935 ELECTRTC MOTOR VEHI CLE CREDI T AMOUI i I F:
. . . $0. 00
F89l - 0 AI , TERNATI VE MOTOR VEHf CI , E CREDf T AMOI TNT:
. . . $0. 00
9I I TI 9l I Pl : : ' "'
. so. oo
r v r , * L K E U T I D : . . .
. $ 0 . 0 0
TOTAI, CREDITS PER CoMPII|ER:
. .
g0.00
I NCOME TAX AFTER CREDI TS
pER
COMPUTER: . . . .
. . . . S8G3. 00
Other Taxes
s E T A X :
. . . . $ o . o o
S E T A X P E R COMP I I | E R: . . . .
. . . . $ 0 . 0 0
SOCI AI SECURI TY AND MEDI CARE TAX ON UNREPORTED TI pS: .
. . $0. 00
socrAl , SECURTTY AND MEDTCARE TAx oN IINREPORTED Trps
pER
coMpurER: ..$o.oo
TAx oN QUALI FI ED
PLANS F5329
( PR) : . .
' ' $27
' 00
TAX ON QUA] , I FI ED
PI , ANS F5329 PER COMPUTER: . . . .
. $27. 00
I RAF TAX PER COMPUTER: . . . . " $ 0 ' 0 0
TP TAX FIGURES
(REDUCED BY IRAF) PER COMPIITER: . . . . . . $89O. OO
I MF TOTA! TAx
( REDUCED BY I RAF) PER COMPI I TER: . - - -
" " $890' 00
'
OTHER TAXES PER COMPUI ER: " "
' $0' 00
UNPAI D FI CA ON REPORTED TI PS: .
' ' ' ' $ 0 ' 0 0
o r HE R T A X E S : ' " " " $ o ' o o
RECAPTURE TAX: F8 5 l - L : . . . . . "
' $ 0 ' 0 0
HOUSEHOLD EMPLOYMEN| TAXES:
' $0' 00
HOUSEHOLD EMPLOYMENT TAXES PER COMPII|ER: "
' $0' 00
RECAPTURE TAXES:
' $0' 00
TOTAI ASSESSMEI { I PER COMPTJI ER; "
' $890' 00
TOTAL TAX LIABILITIT TP FIGURES:
' ' ' $890
' 00
TOTAI , TAX LI ABI LI TY TP FI GURES PER COMPI I : | ER: - . . .
" "$890' 00
PaymenEs
FEDERAL I NCOME TAX WI TI 1HELD: . . . .
' $1, 489' 00
COBRA PREMf UM SLI BSI DY: "$0' 00
ESTI MATED TAx PAYMENTS: . . . .
' $0' 00
OTHER PAYMENT CREDI T:
' $0' 00
MAKI NG WORK PAY AND GOV' T RET CREDI T PER COMPUTER: - . . .
' $0' 00
REFUNDABLE EDUCATION CREDIT: "$0' 00
REFUNDABLE EDUCATI ON CREDI T PER COMPI I I ER: . . . . " "$0' 00
REFUNDABLE EDUCATfON CREDIT VERIFIED: " "$0' 00
EARNED I NCOME CREDI T: "
' $0' 00
EARNED I NCOME CREDI T PER COMPUTER: . . . .
. ' ' $0' 00
EARNED INCOME CREDIT NONTAXABLE COMBAT PAY:..
"
' $0' 00
SCHEDIJLE 8812 NONTAXABLE COMBAT PAY:. -
"$0' 00
EXCESS SOCI AL SECURI TY & RRTA TAX WI THHELD: . . . . . " " " $0' 00
scHEDUr , E 8812 TOT SS/ MEDTCARE WTTHHELD:
. . - . $0- 00
SCHEDULE 8812 ADDI TI ONAL CHf LD TAX CREDI T: " "$0' 00
SCEEDULE 8812 ADDITIONAL CHILD TAx CREDIT PER COMPUTER:
" " "$0' 00
SCHEDULE 881- 2 ADDI TI ONAL CHI LD TAX CREDI T VERI FI ED:
" "$0' 00
AMOUNT PAI D WI TH FORM 4 8 6 8 : . . . . . " " $ 0 ' 0 0
FORM 2439 REGITLATED INVESTMENT COMPANY CREDIT: "
' $0' 00
FORM 4136 CREDI T FOR FEDERAL TAx ON FUELS: "
' $0' 00
FORM 4135 CREDI T FOR FEDERAL TAX ON FUELS PER COMPUTER:
""' $0' 00
HEALTH COVERAGE TX CR: F8885:
' '
$0
' 00
FORM 8801 REFI JNDABLE CREDI T FOR PRI OR YEAR MI N. TAX: . '
" "
' $0' 00
FI RST TI ME HOME BI r yER CREDI T PER COMPI I TER: - . . . " ' $0' 00
FI RST TI ME HOME B{ f vER CREDI T: " " "$0' 00
FI RST TI ME HOME BUYER CREDI T VERI FI ED: "
' $0' 00
PRIMARY NAP FIRST TIME HOME BUYER INSTAI,LMENT AMT:
" "$0' 00
SECONDARY NAP FIRST TIME HOME BITYER INSTALLMEMT AMT:
"' $0' 00
FIRST TIME HOMEBUYER CREDIT REPAYMENT AMOUNI: "
' $0' 00
FORM 25s5 COMBINED EARNED INCOME AMOIJI{T PER COMPIITER:.
"' "
' $0' 00
FORM 5405 TOTAL HOMEBUYERS CREDI T REPAYMENT PER COMPUTER: ""
"""$0' 00
SMALL EMPI , OYER I I EALTH I NSURANCE PER COMPUTER: . - - - """$0' 00
SMALJ, EMPLOYER HEALr I I I NSI ] RANCE PER COMPUTER
( 2) : . . . . $O. OO
FORM 2439, 8801, and OTHER CREDI T TOTAL AMf : - - . ' $0' 00
Tor Ar ' PAYMENTS: "
' $1' 489' oo
TOTAL PAYMENTS PER COMPUTER: "$1, 489' 00
Refund or Amount Owed
REFUND AMo u NT: " " ' $ - 5 9 9 ' o o
APPLI ED TO NEXT YEi AR' S ESTI MATED TAX: . .
" "$0' 00
ESTI MATED TAX PENATTY: . . . . . " " " $ 0 ' 0 0
TAX ON I NCOME LESS STATE REFUND PER COMPU1I ER: . . - - " " $0' 00
BAI , DUE/ OVER PYMI USI NG TP FI G PER COMPUTER:
. . $_599. 00
BAL DUE/ OVER PYMT USI NG COMPI I TER FI GURES: . . . . . .
" " ' $- 599' 00
FORM 8888 TOTAI REFUND PER COMPII|ER: - . . .
"
$0
' 00
Thi rd Party Desi gi nee
THIRD PARTY DESIGNEE ID NIJMBER:
AI I THORI ZATI ON I NDI CATOR: . . . . " " " " " 0
THIRD PARTY DESIGNEE NAME:.
Form 8863
-
Educati on Credi ts
(Hope and Li feti me Learni ng credi Ls)
PART III
.
AL],OWABIE EDUCATION CREDITS
GROSS EDUCATI ON CR PER COMPUTER: . . . . " " $0' 00
TOTAL EDUCATI ON CREDI T AMOUNT: " ' " ' $0' 00
TOTAL EDUCATI ON CREDI T AMOUI { : I PER COMPUTER: . . . . ""' $0' 00
Thi s Product Contai ns Sensi ti ve Taxpayer Data