9 O, 10¢/pen a my Social Security account
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FORM SSA-1099 - SOC!AL SECUR|TY BENEFIT STATEMENT
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13 201 4 » PART o:= Yoon sociAL secumrr BENEFITS sHowN u-
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t BOX 5 MAV BE TAXABLE lNCOME.
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' SEE THE RE\IERSE FOR MORE lNFORMATlON_ g
l §5;1. Name k lBox 2. Beneficiary’s Social Secun't_v Number §§
l PAUL a LARSON l 386.40-3920 §§
fir-E:)x 3. Benefits Paid in 2014 Box 4. Bsnefits L~`tepaa`d :o SSA in 2014 _Box|'s,"Net ._Benefits to'r`- 2_01_4':¢52»¢' §
5 316,620.00 . ; $700.00 ' ' `.`;'.$1~5§920.00 §
il DESCR|PTION OF AMDUNT m BOX 3 l DESCRIPT|ON_ OF AMOUNT lN BOX 4
ii Paid by check or direct deposit $15.920.00 ll Decluctions for work or other j
le Deductions for work or other ‘r adjustments $700.00 l
l adjustments $‘700400 ° Beneiits repaid to SSA in 2014 $700.00
.‘ Total Adclit:ions $16,620.00 § l
il Beneii'ts for 2014 $16,620.()() l 11
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il ll Bo:< 6. Volumary Federal tacoma Tax Withheid
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l j Box 7.Ada`ress
§ l' PAUL- A L.»¢"H`€SO.-“l
_l PU BOX 524{)01
§ 1 .H ()l,lSTC/N TX` 7’.’052-40(}1
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l § F.Box 8, Cla.‘m Number (Us¢»;~ this nurr.~ber ff you need to contact S$A.] §§
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§ ‘ l XXX-XX-XXXX!1 §§
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, crm SSA-1099-SM (1~.2015)
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