Form SSA-1099 Social Security Benefit Statement

Please complete the form below by entering the information EXACTLY as it appears on your Form SSA-1099
Use the Tab key to move to the next field. An asterisk ( * ) indicates a required field.

* Your E-mail Address:

FORM SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT

2005

  • PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME

* Box 1. Name

* Box 2. Beneficiary’s Social Security Number

Box 3. Benefits Paid in 2005

Box 4. Benefits Repaid to SSA in 2005

* Box 5. Net Benefits for 2005

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

Form SSA-1099-SM

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