South Carolina Department of 
                                            Coupon 4: 
 Revenue                                    Primary SSN:      555-55-5555 
 Data to be Used for Creating               Secondary SSN:    777-77-7777  
                                            Primary Taxpayer: Sammy McOwes  
 Sample Forms for Income 
                                            Secondary Taxpayer: Sally McOwes  
 (2024 SC4868)                              Address:          123 Bill Lane Apt 23A 
 Revised 05-15-2024                                           Anywhere SC 
 You must submit 1 form for each example.   Zip Plus 4:       29999-0023 
                                            Composite Filer:  No 
 Coupon 1:                                   
 Primary SSN:       111-11-1111             Period Covered:          12-24 
 Secondary SSN:      None                   Payment amount:        $100.00 
 Primary Taxpayer:   Income Jones            
 Secondary Taxpayer:  NA                    Coupon 5: 
 Address:            123 Filer Way          Primary SSN:              888-88-8888 
                     Anywhere, SC           Secondary SSN:    None 
 Zip Plus 4:         29999-1234             Primary Taxpayer: Owing O Connor 
 Composite Filer:    Yes                    Secondary Taxpayer:  NA 
                                            Address:          Blurnfad     15 
Period Covered:      12-24                   
                                                              41516 Frankfurt Germany 
Payment amount:      $100.00 
                                            Zip Plus 4:       00000 
                                            Composite Filer:  Yes 
 Coupon 2:                                                      
                                            Period Covered:   12-24 
 Primary SSN:        111-11-1111 
                                            Payment amount:   $148.00 
 Secondary SSN:      222-22-2222                                
 Primary Taxpayer:   Paying Joe                                 
 Secondary Taxpayer: Spending Joe                               
 Address:            PO Box 1234                                
                     APO AP                                     
 Zip Plus 4:         29999                                      
 Composite Filer:    No                                         
 Period Covered:     12-24                                      
 Payment amount:     $200.00                                   

 Coupon 3: 
 Primary SSN:        333-33-3333                               
 Secondary SSN:      444-44-4444                               
 Primary Taxpayer:   Penny Pa                                  
 Secondary Taxpayer: Doll Pa                                   
 Address:            PO Box 1                                  
                     Anywhere SC                               
 Zip Plus 4:         29999-1204                                
 Composite Filer:    No                                        
 Period Covered:     12-24                                     
 Payment amount:     $1.00