Form SSA-1099-R-OP1 (01-2022)

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FORM SSA-1099 -- SOCIAL SECURITY BENEFIT STATEMENT
• PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME.
2021 • SEE FACTS ABOUT YOUR 2021 SOCIAL SECURITY BENEFIT STATEMENT AND NOTICE 703
FOR MORE INFORMATION.
Box 1. Name Box 2. Beneficiary's Social Security Number
FRANCIS W ALBOLINO 137-36-1156

Box 3. Benefits paid in 2021 Box 4. Benefits Repaid to SSA in 2021 Box 5. Net Benefits for 2021 (Box 3 minus Box 4)
$28,014.00 NONE $28,014.00

DESCRIPTION OF AMOUNT IN BOX 3 DESCRIPTION OF AMOUNT IN BOX 4

Paid by check or Direct deposit $24,396.00
Medicare Part B premiums NONE
deducted from your benefits $1,782.00
Voluntary Federal Income Tax Withheld $1,836.00
Total Additions $28,014.00
Benefits for 2021 $28,014.00

Box 6. Voluntary Federal Income Tax Withheld

$1,836.00

Box 7. Address
FRANCIS W ALBOLINO
434 HEATH PLACE
HACKENSACK NJ 07601-1438

Box 8. Claim Number

(Use this number if you need to contact SSA.)
137-36-1156A

DO NOT RETURN THIS FORM TO SSA OR IRS

Form SSA-1099-F2-INST (01-2022)
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Facts About Your 2021 Social Security Benefit Statement
Your 2021 Social Security Benefit Statement is enclosed with this form. Use it, along with the information below, to see if
part of your Social Security benefits may be taxable.
What You Need to Do
Use the 2021 statement with the Box 2—"Social Security Number,"— Box 4—"Benefits Repaid to SSA in
shows the Social Security number of 2021,"— shows the total amount of
Internal Revenue Service (IRS) Notice
the person shown in Box 1 if we have benefits you repaid us in 2021. We
703 on the reverse, to see if any part the number. show items that apply to you in the
of your Social Security benefits are column headed "Description of Amount
taxable. Do not return this form to us Box 3—"Benefits Paid in 2021,"— in Box 4."
or to the IRS. Do not attach it to your shows the total amount of Social
income tax return. Keep the original forSecurity we paid you in 2021. This Box 5—"Net Benefits for 2021,"—
your records. We also are sending this amount may not agree with the shows the amount in Box 3 minus
benefit information to the IRS. We did payments you actually received in the amount in Box 4. An amount in
2021. This is because it may include parentheses is a negative amount.
not include your SSI benefits, if any, on
money we withheld for deductions such Enter this amount on line A of IRS
this statement. You may wish to keep as Medicare Part B (medical insurance) Notice 703 to see if any of your Social
this statement as proof of your income premiums, Medicare Advantage or Security benefits are taxable.
for use with public assistance. If you prescription drug coverage premiums
do not receive public assistance and you requested to be withheld from Box 6—"Voluntary Federal Income
you do not owe taxes on your Social your benefits, and any income-related Tax Withheld,"— shows the total
Security benefits, you may ignore this monthly adjustment amount you amount of benefits voluntarily withheld
form. are required to pay for Part B or and paid for Federal income tax.
prescription drug coverage. Also, it may Include this amount on your income tax
Who Receives This Statement leave out some payments that are not return as tax withheld.
We must, by law, send you a statement taxed by the IRS. All items that apply
that shows the Social Security benefits to you are listed in the "Description of If You Have Any Questions
you received or repaid in 2021. We Amount in Box 3." NOTE: If you have If you have any questions about the
send separate statements to each a "Treasury Benefit Payment Offset, amounts on this form, call Social
person when we combine your check Garnishment and/or Tax levy" amount Security at 1-800-772-1213. Please
with another person's check. If you shown and need to know what type have this form with you. Please use
get more than one check each month, of offset is involved, contact SSA at the claim number shown in Box 8 if you
we may send you more than one 1-800-772-1213 for an explanation. If contact SSA. If you have questions
statement. you have a tax debt question, call the about how to figure the taxable part of
IRS at 1-800-829-1040. your Social Security benefits after you
Explanations of Items Any payments we made in 2021 for complete Notice 703, visit IRS.gov and
enter "social security income" in the
Box 1—"Name, "— shows the name of earlier years are shown in a separate search box.
the person for whom we paid benefits. column.
Facts About Computer Matching Programs
Congress passed a law (PL 100-503) State, or local government agencies. law allows us to check this way even
in 1988 that says you have a right to Many agencies may use matching if you do not agree to it. We may also
know that we may use information you programs to find or prove that a person share information about you with other
give us when we match records by qualifies for benefits paid by the government agencies that pay benefits.
computer. Below, we tell you about Federal government. They will use this information in their
computer matching and how it may computer matching programs.
How Do Computer Matching
affect you.
Programs Affect You? If You Want More Facts
What Are Computer Matching On forms that you fill out for us you If you want to learn more about
Programs? give us information about yourself. computer matching or how we use
Computer matching programs compare Sometimes, we check the information information about you, please contact
Social Security and/or Medicare you, and others, give us. We use any Social Security office.
records with those of other Federal, computer matching to do checking. The