Publication 915 - Social Security And Equivalent Railroad Retirement Benefits - Internal Revenue Service - 2001 Page 19
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28FORM SSA-1099 – SOCIAL SECURITY BENEFIT STATEMENT
● PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME.
2001
● SEE THE REVERSE FOR MORE INFORMATION.
Box 1. Name
Box 2. Beneficiary’s Social Security Number
Box 3. Benefits Paid in 2001
Box 4. Benefits Repaid to SSA in 2001
Box 5. Net Benefits for 2001 (Box 3 minus Box 4)
DESCRIPTION OF AMOUNT IN BOX 3
DESCRIPTION OF AMOUNT IN BOX 4
Box 6. Voluntary Federal Income Tax Withholding
Box 7. Address
Box 8. Claim Number
(Use this number if you need to contact SSA.)
Form SSA-1099-SM (1-2002)
DO NOT RETURN THIS FORM TO SSA OR IRS
Box 1—Name
Appendix
The name shown in this box refers to the person for whom
the social security benefits shown on the statement were
This appendix explains items shown on Form SSA–1099
paid. If you received benefits for yourself, your name will
and Form RRB – 1099. Forms SSA – 1042S and
be shown.
RRB –1042S, for nonresident aliens, contain the same
items plus a few additional ones. These are also explained.
Box 2—Beneficiary’s Social Security
The illustrated versions of Forms SSA– 1099,
!
SSA–1042S, RRB – 1099, and RRB-1042S in
Number
this appendix are proof copies of the forms as
CAUTION
This is the U.S. social security number, if known, of the
they appeared when this publication went to print. The
person named in box 1.
information on the illustrated forms should be essentially
the same as the information on the form you received from
In all your correspondence with the SSA, be sure
either the SSA or the RRB. You should, however, compare
TIP
to use the claim number shown in box 8.
the form you received with the one shown in this publica-
tion to note any differences.
Form SSA–1099
Box 3—Benefits Paid in 2001
Every person who received social security benefits will
The figure shown in this box is the total benefits paid in
receive a Form SSA– 1099. If you receive benefits on more
2001 to you (the person named in box 1). This figure may
than one social security record, you may get more than
not agree with the amounts you actually received because
one Form SSA– 1099. IRS Notice 703 will be enclosed
adjustments may have been made to your benefits before
with this form. It contains a worksheet to help you figure if
you received them. An asterisk (*) after the figure shown in
any of your benefits are taxable. Do not mail Notice 703 to
this box means that it includes benefits received in 2001 for
either the IRS or the SSA.
one or more earlier years.
Page 19
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