CORRECTED (if checked) RECIPIENT'S/LENDER'S name, street address, city or town, state or OMB No. 1545-1576 province, country, ZIP or foreign postal code, and telephone number EDUCATION LOANS, INC. Student 45 LEARNING LANE 2021 Loan Interest YOUR CITY, YS XXXXX Statement 800-555-1041 + Form 1098-E RECIPIENT'S TIN BORROWER'S TIN 1 Student loan interest received by lender Copy B 07-3651103 365-00-3065 $ 1,222.22 For Borrower BORROWER'S name This is important tax SYDNEY MARTIN information and is being furnished to the IRS. If you are required to file a Street address (including apt. no.) return, a negligence penalty or other 6515 NOBLE STREET sanction may be imposed on you if the City or town, state or province, country, and ZIP or foreign postal code IRS determines that an YOUR CITY, YS XXXXX underpayment of tax results because you Account number (see instructions) 2 If checked, box 1 does not include loan origination overstated a deduction 0912672 fees and/or capitalized interest for loans made before for student loan interest. September 1, 2004 Form 1098-E (keep for your records) www.irs.gov/Form1098E Department of the Treasury - Internal Revenue Service2021 Child Care Expense Summary m Child Care Provider's Identification: Name: UNIFIED SCHOOL DISTRICT AFTER SCHOOL CARE Address: 6955 SEUSS AVENUE City. state, and ZIP code: Your City, vs xxxxx Tele hone: (XXX)555-1234 wnnnnannnuTmmm m: Child Care Expense Information: Child(ren) Names: Fees Charged Amount Paid ROMAN DIAZ 0110112021 - 0511412021 19 weeks @ $3751week $ 7,125.00 $7,125.00 "You may be able to claim a tax credit for child Total Charged Total Paid care expenses. Please consult your tax professional." $7,125.00 $7,125.00 Form 1095-A Health Insurance Marketplace Statement VOID OMB No. 1545-2232 Department of the Treasury Do not attach to your tax return. Keep for your records. CORRECTED 2021 Internal Revenue Service >Go to www.irs.gov/Form1095A for instructions and the latest information. Part | Recipient Information 1 Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer's name YS LC1241759894 GENERAL INSURANCE COMPANY 4 Recipient's name 5 Recipient's SSN 6 Recipient's date of birth SYDNEY MARTIN 365-00-3065 4/15/1983 7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth 10 Policy start date 11 Policy termination date 12 Street address (including apartment no.) 03/01/2021 12/31/2021 6515 NOBLE STREET 13 City or town 14 State or province 15 Country and ZIP or foreign postal code YOUR CITY YS XXXXX Part II Covered Individuals A. Covered individual name B. Covered individual SSN C. Covered individual D. Coverage start date E. Coverage termination date date of birth 16 SYDNEY MARTIN 365-00-3065 04/15/1983 03/01/2021 12/31/2021 17 18 19 20 Part III Coverage Information Month A. Monthly enrollment premiums B. Monthly second lowest cost silver C. Monthly advance payment of plan (SLCSP) premium premium tax credit 21 January $ 0.00 $ 0.00 $ 0.00 22 February $ 0.00 $ 0.00 $ 0.00 23 March $ 391.00 $ 344.00 $ 211.00 24 April $ 391.00 $ 344.00 $ 211.00 25 May $ 391.00 $ 344.00 $ 211.00 26 June $ 391.00 $ 344.00 $ 211.00 27 July $ 391.00 $ 344.00 $ 211.00 28 August $ 391.00 $ 344.00 $ 211.00 29 September $ 391.00 $ 344.00 $ 211.00 30 October $ 391.00 $ 344.00 $ 211.00 31 November $ 391.00 $ 344.00 $ 211.00 $ 391.00 $ 344.00 $ 211.00 32 December $ 3,910.00 $ 3,440.00 $ 2,110.00 33 Annual Totals For Privacy Act and Paperwork Reduction Act Notice, see separate instructions Cat. No. 60703Q Form 1095-A (2021)CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP | Payer's RTN (optional) OMB No. 1545-0112 or foreign postal code, and telephone no. 2021 Interest SEMINOLE BANK AND TRUST 1 Interest income 57 SEMINOLE WAY Income YOUR CITY, YS XXXXX $ 117.22 Form 1099-INT 800-555-1005 2 Early withdrawal penalty Copy B PAYER'S TIN RECIPIENT'S TIN $ For Recipient 3 Interest on U.S. Savings Bonds and Treas. obligations 07-3651102 365-00-3065 $ RECIPIENT'S name 4 Federal income tax withheld 5 Investment expenses This is important tax $ $ information and is SYDNEY MARTIN being furnished to the 6 Foreign tax paid 7 Foreign country or U.S. possession IRS. If you are Street address (including apt. no.) $ required to file a 8 Tax-exempt interest 9 Specified private activity bond return, a negligence 6515 NOBLE STREET interest penalty or other sanction may be City or town, state or province, country, and ZIP or foreign postal code $ $ imposed on you if 10 Market discount 11 Bond premium this income is YOUR CITY, YS XXXXX taxable and the IRS determines that it has FATCA filing $ $ not been reported. requirement 12 Bond premium on Treasury obligations | 13 Bond premium on tax-exempt bond $ $ Account number (see instructions) 14 Tax-exempt and tax credit 15 State 16 State identification no. 17 State tax withheld bond CUSIP no. SBT0987635 Form 1099-INT (keep for your records) www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Servicea Employee's social security number Safe, accurate, Visit the IRS website at 365-00-3065 OMB No. 1545-0008 FAST! Use use file www.irs.gov/efile b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld 07-3651101 38,265.44 2,591.21 c Employer's name, address, and ZIP code 3 Social security wages Social security tax withheld UNIVERSITY ATHLETIC 38,265.44 2,372.46 5 Medicare wages and tips 6 Medicare tax withheld 1 UNIVERSITY WAY 38,265.44 554.85 YOUR CITY, YS XXXXX 7 Social security tips 8 Allocated tips d Control number 9 10 Dependent care benefits 3,562.50 e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12 SYDNEY MARTIN 13 Statutory Retirement Third-party 12b 6515 NOBLE STREET employes sick pay YOUR CITY, YS XXXXX 14 Other 12c 1000 12d f Employee's address and ZIP code 15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name YS 073651101A 38,265.44 740.00 Form W-2 Wage and Tax Statement 2021 Department of the Treasury-Internal Revenue Service Copy B-To Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service.CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP 1a Total ordinary dividends OMB No. 1545-0110 or foreign postal code, and telephone no. INVESTMENT MASTERS $ 435.00 2021 Dividends and 2626 FINANCIAL WAY 1b Qualified dividends Distributions YOUR CITY, YS XXXXX $ 435.00 Form 1099-DIV (888) 311-2828 2a Total capital gain distr 2b Unrecap. Sec. 1250 gain Copy B $ $ For Recipient PAYER'S TIN RECIPIENT'S TIN 2c Section 1202 gain 2d Collectibles (28%) gain 07-3651105 365-00-3065 $ $ 2e Section 897 ordinary dividends 2f Section 897 capital gain $ RECIPIENT'S name 3 Nondividend distributions 4 Federal income tax withheld This is important tax SYDNEY MARTIN information and is 5 Section 199A dividends 6 Investment expenses being furnished to Street address (including apt. no.) $ the IRS. If you are required to file a 6515 NOBLE STREET 7 Foreign tax paid 8 Foreign country or U.S. possession return, a negligence penalty or other sanction may be City or town, state or province, country, and ZIP or foreign postal code $ imposed on you if this income is taxable YOUR CITY, YS XXXXX 9 Cash liquidation distributions | 10 Noncash liquidation distributions and the IRS $ $ determines that it has not been reported. FATCA filing 11 Exempt-interest dividends 12 Specified private activity requirement bond interest dividends $ $ Account number (see instructions) 13 State 14 State identification no. 15 State tax withheld $ Form 1099-DIV (keep for your records) www.irs.gov/Form 1099DIV Department of the Treasury - Internal Revenue Service