South Carolina Department of Revenue 
 Data to be Used for Creating Sample Forms for Income (SC1041ES) 2024 
 Revised 05-15-2023 
 
 You must submit 1 form for each example. 
 
 Coupon 1:                                           Coupon 5:        
 FEIN:               57-0000000                      FEIN:            57-1234567 
 Name:               Income Jones Family Trust       Name:            Penny Pa Family Trust 
                                                       
 Address:            123 Time to File                Address:         4 Quarters Lane 
                     Anywhere SC 29999                                Racing SC 29456 
 Period Covered:     03-24                           Period Covered:  03-24 
 Payment amount:     $100.00                         Payment amount:  $148.00 
                                                      
 Coupon 2:           
 FEIN:               57-1111111 
 Name:               Fiduciary Family Trust           
                                                      
 Address:            PO Box 1234                      
                     Anywhere SC 29998                
 Period Covered:     06-24 
 Payment amount:     $200.00                          

 Coupon 3:           
 FEIN:               57-2222222 
 Name:               Declaration Family Trust         
                                                      
 Address:            PO Box 1                         
                     Anywhere SC 29999-1204           
 Period Covered:     09-24 
 Payment amount:     $175.00                          

 Coupon 4:           
 FEIN:               57-4444444 
 Name:               Owes Family Trust                
                                                      
 Address:            123 Bill Lane Apt 23A            
                     Anywhere SC 29999-0023           
 Period Covered:     12-24 
 Payment amount:     $100.00                          
 
 FEIN should never include a social security number.