DO NOT RETURN THIS FORM TO SSA OR IRS
Box 8. Claim Number (Use this number if you need to contact SSA.)
Printed on recycled paper
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U
U.S. GOVERNMENT PUBLISHING OFFICE: 2017-398-203/60003
VISIT OUR WEBSITE WWW.SOCIALSECURITY.GOV
KEEP THIS FORM FOR PROOF OF SOCIAL SECURITY BENEFITS
FIRST-CLASS MAIL
PRESORTED
POSTAGE AND FEES PAID
SOCIAL SECURITY
ADMINISTRATION
PERMIT NO. G-11
F
2
2
Box 7. Address
Box 6. Voluntary Federal Income Tax Withheld
DESCRIPTION OF AMOUNT IN BOX 4
IMPORTANT: TAX INFORMATION ENCLOSED
Form SSA-1099-SM (1-2017)
12/1/05 5:40 PM Page
12/1/05 5:40 PM Page
DESCRIPTION OF AMOUNT IN BOX 3
Box 5. Net Benefits for 2016 (Box 3 minus Box 4)
Box 3. Benefits Paid in 2016
Box 4. Benefits Repaid to SSA in 2016
Box 2. Beneficiary’s Social Security Number
• PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME.
• SEE THE REVERSE FOR MORE INFORMATION.
Box 1. Name
2016
FORM SSA-1099 – SOCIAL SECURITY BENEFIT STATEMENT
OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE, $300
Open a my Social Security account
SocialSecurity.gov
Form SSA-1099-SM (1-2017)
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