South Carolina Department of 
 Revenue 
 Data to be Used for Creating Sample 
 Forms for Income (SC1040-V) (2023) 
 Revised 05-15-2023 
 
 You must submit 1 form for each example, for a       
 total of five test cases. Submissions will not be    
 approved if the correct number of test cases is not  
 provided and/or South Carolina test cases are not    
 used.                                                
 
 Coupon 1:                                            Coupon 4: 
 Primary SSN:       111-11-1111                       Primary SSN:      555-55-5555 
 Secondary SSN:     None                              Secondary SSN:    777-77-7777 
 Primary Taxpayer:  Income Jones                      Primary Taxpayer: Sammy McOwes 
 Secondary Taxpayer:  NA                              Secondary Taxpayer: Sally McOwes 
 Address:           123 Time to File                  Address:          123 Bill Lane Apt 23A 
                    Anywhere SC 29999                                   Anywhere SC 29999 
 Composite Filer:   Yes                               Composite Filer:  No 
 Period Covered:    12-23                             Period Covered:   12-23 
 Payment amount:    $100.00                           Payment amount:   $100.00 
                                                      
 Coupon 2:                                            
 Primary SSN:       666-66-6666                       
 Secondary SSN:     222-22-2222                       
 Primary Taxpayer:  Paying Joe 
 Secondary Taxpayer: Spending Joe                     Coupon 5: 
 Address:           PO Box 1234                       Primary SSN:      888-88-8888 
                    APO AP 29999                      Secondary SSN:    None 
 Composite Filer:   No                                Primary Taxpayer: Owing O Connor 
 Period Covered:    12-23                             Secondary Taxpayer:  NA 
 Payment amount:    $200.00                           Address:          Blurnfad 15 
                                                                        41516 Frankfurt Germany 
 Coupon 3:                                            Composite Filer:  Yes 
 Primary SSN:       333-33-3333                       Period Covered:   12-23 
 Secondary SSN:     444-44-4444                       Payment amount:   $148.00 
 Primary Taxpayer:  Penny Pa 
 Secondary Taxpayer: Doll Pa 
 Address:           PO Box 1 
                    Anywhere SC 29999-1204 
 Composite Filer:   No 
 Period Covered:    12-23 
 Payment amount:    $1.00