South Carolina Department of 
 Revenue 
 Data to be Used for Creating Sample 
 Forms for Income (SC1040-V) (2024) 
 Revised 05-15-2024 
 
 You must submit 1 form for each example, for a        Coupon 4: 
 total of five test cases. Submissions will not be      Primary SSN:      555-55-5555 
 approved if the correct number of test cases is not    Secondary SSN:    777-77-7777  
 provided and/or South Carolina test cases are not      Primary Taxpayer: Sammy McOwes  
 used.                                                  Secondary Taxpayer: Sally McOwes 
                                                        Address:          123 Bill Lane Apt 23A  
 Coupon 1:                                                                                  Anywhere SC 29999 
 Primary SSN:       111-11-1111                         Composite Filer:  No  
 Secondary SSN:     None                                Period Covered:   12-24 
 Primary Taxpayer:  Income Jones                        Payment amount:   $100.00 
 Secondary Taxpayer:  NA                                
 Address:           123 Time to File  
                                                        Coupon 5: 
                                     Anywhere SC 29999 
                                                        Primary SSN:      888-88-8888 
 Composite Filer:   Yes  
                                                        Secondary SSN:    None 
 Period Covered:    12-24 
                                                        Primary Taxpayer: Owing O Connor  
 Payment amount:    $100.00 
                                                        Secondary Taxpayer:  NA 
                                                        Address:          Blurnfad 15 
 Coupon 2:          
                                                                          41516 Frankfurt Germany 
 Primary SSN:       666-66-6666 
                                                        Composite Filer:  Yes 
 Secondary SSN:     222-22-2222 
                                                         Period Covered:  12-24 
 Primary Taxpayer:  Paying Joe 
                                                        Payment amount:   $148.00 
 Secondary Taxpayer: Spending Joe  
 Address:           PO Box 1234 
                    APO AP 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 29999-1204 
 Composite Filer:   No  
 Period Covered:    12-24 
 Payment amount:    $1.00