Form Ssa-1099 - Social Security Benefit Statement - Social Security Administration - 2016

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FORM SSA-1099 – SOCIAL SECURITY BENEFIT STATEMENT
2016
• 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 2016
Box 4. Benefits Repaid to SSA in 2016
Box 5. Net Benefits for 2016
(Box 3 minus Box 4)
DESCRIPTION OF AMOUNT IN BOX 3
DESCRIPTION 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 (1-2017)
IMPORTANT: TAX INFORMATION ENCLOSED
KEEP THIS FORM FOR PROOF OF SOCIAL SECURITY BENEFITS
VISIT OUR WEBSITE
F
Printed on recycled paper
U.S. GOVERNMENT PUBLISHING OFFICE:
2017-398-203/60003
U
LIFT TO OPEN

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