Form Ssa-1099-Sm - Social Security Benefit Statement

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FORM SSA-1099 – SOCIAL SECURITY BENEFIT STATEMENT
2015
• PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME.
• SEE THE REVERSE FOR MORE INFORMATION.
Box 1. Name
Box 2. Beneficiary’s Social Security Number
Box 3. Benefits Paid in 2015
Box 4. Benefits Repaid to SSA in 2015
Box 5. Net Benefits for 2015
(Box 3 minus Box 4)
DESCRIPTION OF AMOUNT IN BOX
3
D
ESCRIPTION OF AMOUNT IN BOX 4
Box 6. Voluntary Federal Income Tax Withheld
Box 7. Address
Box 8. Claim Number (Use this number if you need to contact SSA.)
DO NOT RETURN THIS FORM TO SSA OR IRS
Form SSA-1099-SM (1-2016)

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