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
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FORM SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT
2001	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 2001		Box 4. Benefits Repaid to SSA in 2001		* Box 5. Net Benefits for 2001
DESCRIPTION OF AMOUNT IN BOX 4			DESCRIPTION OF AMOUNT IN BOX 4
			Box 6. Voluntary Federal Income Tax Withheld
			Box 7. Address
			Box 8. Address

Form SSA-1099-SM

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