South Carolina Department of Revenue 
  Data to be Used for Creating Sample Forms for Income (2023 SC4868) 
  Revised 05-15-2023 
 
  You must submit 1 form for each example.   
                                             
  Coupon 1:                                  Coupon 4: 
  Primary SSN:       111-11-1111             Primary SSN:      555-55-5555 
  Secondary SSN:      None                   Secondary SSN:    777-77-7777 Primary 
  Primary Taxpayer:   Income Jones           Taxpayer:         Sammy McOwes 
  Secondary Taxpayer:  NA                    Secondary Taxpayer: Sally McOwes 
  Address:            123 Time to File       Address:          123 Bill Lane Apt 23A 
                      Anywhere SC                              Anywhere SC 
  Zip Plus 4:         29999-1234             Zip Plus 4:       29999-0023 
  Composite Filer:    Yes                    Composite Filer:  No 
  Period Covered:     12-23                  Period Covered:    12-23 
  Payment amount:     $100.00                Payment amount:    $100.00 
                                             Coupon 5: 
  Coupon 2:                                  Primary SSN:       888-88-8888 
  Primary SSN:        111-11-1111            Secondary SSN:     None 
  Secondary SSN:      222-22-2222            Primary Taxpayer:  Owing O Connor 
  Primary Taxpayer:   Paying Joe             Secondary Taxpayer:  NA 
  Secondary Taxpayer: Spending Joe           Address:           Blurnfad 15 
  Address:            PO Box 1234                               41516 Frankfurt Germany 
                      APO AP                 Zip Plus 4:        00000 
  Zip Plus 4:         29999                  Composite Filer:   Yes 
  Composite Filer:    No                     Period Covered:    12-23 
  Period Covered:     12-23                  Payment amount:    $148.00 
  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:     12-23                                     
  Payment amount:     $1.00