Box - Social Security Administration
[Pages:1]US001_002BW_14TNH0_PREP6.indd 2
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
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Box 8. Claim Number (Use this number if you need to contact SSA.)
Form SSA-1099-SM (1-2017)
DO NOT RETURN THIS FORM TO SSA OR IRS
IMPORTANT: TAX INFORMATION ENCLOSED
KEEP THIS FORM FOR PROOF OF SOCIAL SECURITY BENEFITS VISIT OUR WEBSITE WWW.
F Printed on recycled paper
U.S. GOVERNMENT PUBLISHING OFFICE: 2017-398-203/60003 U
FOLD & TEAR OFF STUB
2015_v01_Prep9_Layout 1 8/3/15 10:29 AM Page 1
OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300
Open a my Social Security account
Form SSA-1099-SM (1-2017)
FIRST-CLASS MAIL PRESORTED
POSTAGE AND FEES PAID SOCIAL SECURITY ADMINISTRATION PERMIT NO. G-11
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11/21/16 3:37 PM
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