2 C>, Av‘/
600 WEST MADISON ST 1 ADMiNieTRArioN
CHICAGO IL 60661-2474 PEnMn No.o~si
CJFFlClAL BUSlNE`~:`:-'S
PENA€.TY FOH PQ!VATE L_"S`E, 5.`»3;`~’_‘
PAUL A i_.,ARSON
PO BC)X 524001
HOUSTON TX 77052-4001
ull|l'""lll"l"'lil"h|'mill~tli"i|'li|ll'llu"lh"l""'
Gpen a my Socia/ Security account
._Sonial$eouritv.og_v_%_,__M_M__`|w__“____w____`_ m
l
FORM SSA-1099 - SOClAL SECUH|TY BENEF|T STATEMENT
1 " y ,
z 201 4 ” mm OF yOUH SOC'A'“ SECUR*TY` BENEFITS SHoWN m eox 5 MAY BE TA)< 1. Name lBox 2. Bene(ici'ary’s Soci'al Secun't_v Number l 5
PAUL a mason y l 336\-40.3920 j §
li_`E.*o)< 3. Benefits Paid in 2014 Box 4. Benefits Ftepaid to SSA in 20`14 B_ox| 5. Net Bsnefits'to'i"2014='.¢50)¢`3»1#;0`$‘5¢){~4)-»` §
j 316,620.00 4 l amoco - . ' 1-5,92@. ,.. ~ §
1_` 1 ny _' w
il DESCR|PT|ON OF AMQUNT m BOX 3 l DESCRIP'!"|ONy OF AMOUNT lN BOX 4
ii Paid by check or direct deposit $151920.00 ll Deductions for work or other l
' Deductions for work or other ll a iust:ments S700.00 _l
adjustments $700.00 ; B<=inetits repaid to SSA in 2014 $700.00 l
Total Addita`ons $16,620.00 l '
Benetits for 2014 $16,£§20.0()
vui_._.__ __
Bo:< 6. Voluntary Federal income Tax W.ithheld
l
l
l
l
s
l
l NoNE
l
L
sex 7_ Addr駧
PA UL A .'.".-zLRS()l\"
PU BOX 524{)0'1
H()l.lSTC/‘Z\" TX 7".’052-40’01
…m__ . _l
l
l
l
l
c
l
i_
l
l
l
l"i
l E
_; §
l ,.... _______ » . ,r,_. ___,t. 13
l ti=ox 8. Claim Number t.‘.!se~ this number ifyou need to contact SSA.) §
‘ §
l ' ,
j 336-40-3920A §§
I
z t a
com ssA-ioss-sm (1~2015) ` b °° H__ m 9mm `""’s. F°"M m S,SA 'QF’; ".‘jlis '