Larson, Paul Allan

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 '