I M P O R TA N T: TA X I N F O R M AT I O N E N C L O S E D

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Stuart Poole
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SOCIRL SECURITY RDMINISTRHTION W E S T E R N P R O S R H M S E R U I C E C E N T E R P. O. B O R H 0 6 i RICHMOND^ CR 3H0O2 PRESORTED F I R S T C L A S S M A I L U.S. DEPARTMENT OF H.H.S. PERMIT NO.

1 SOCIRL SECURITY RDMINISTRHTION W E S T E R N P R O S R H M S E R U I C E C E N T E R P. O. B O R H 0 6 i RICHMOND^ CR 3H0O2 PRESORTED F I R S T C L A S S M A I L U.S. DEPARTMENT OF H.H.S. PERMIT NO. G-11 OFFICIAL BUSINESS P E N A L T Y F O R P R I V A T E U S E $ PRESORT FIRST CLASS I M P O R TA N T: TA X I N F O R M AT I O N E N C L O S E D R C CRR-RT SORT».;KRR DC ARTHUR BERL a? RT BR 2 CHNBRIfl CR 33H2S

2 DO NOT RETURN THIS FORM TO SSA OR IRS GENERAL INFORMATION PART OF YOUR SOCIAL SECURITY BENEFITS MAY BE TAXABLE INCOME TO YOU. SEE ENCLOSED IRS NOTICE 703 FOR MORE DETAILS Purpose of This Statement This statement is from the Sociai Security Ad ministration (SSA) and shows Social Security benefit information for Use this statement along with the enclosed Notice 703 to see if any part of your benefits may be taxable for If none of your Social Security benefits are taxable, disregard this form. This information is being sent to the In ternal Revenue Service. Do not'return these forms to SSA or IRS or attach them to your income tax return. This statement does not include any SSI benefits you may have received. W h o R e c e i v e s T h i s S t a t e m e n t Social Security is required by law to send a state ment to each person who received or repaid any Social Security benefits during Separate statements are sent to each person even if his/her benefit checks were combined with those of another. A person who receives more than one check each month may get more than one statement. EXPLANATION OF ITEMS Box 1 "Name" This is the name of the person for whom the Sociai Security benefits shown on this statement were paid. B o x 2 " S o c i a i S e c u r i t y N u m b e r " i f S S A ' s records contain the Sociai Security number for the person listed in Box 1, that person's Sociai Securi ty number will be shown in Box 2. If you need to contact SSA about this statement, always use the c l a i m n u m b e r s h o w n i n B o x 7. B o x 3 " B e n e f i t s f o r " T h i s i s t h e t o t a l amount of Social Security benefits considered paid to you in This amount may not agree with payments you actually received in 1985 since it in cludes such items as amounts withheld to pay Medicare premiums for you, etc., and excludes some payments that are not subject to tax. T h e s e i t e m s a r e a i l l i s t e d i n t h e c o l u m n h e a d e d "Description of Amount in Box 3". Any payments made during 1985 that were for 1984 are included in this total, but shown separately. Box 4 "Benefits Repaid to SSA in 1985" This is the total amount of benefits repaid to SSA in Any items that apply to you are shown in the col umn headed "Description of Amount in Box 4". B o x 5 " N o t B e n e f i t s f o r " T h i s t o t a l i s t h e amount in Box 3 minus the amount in Box 4. A figure in parentheses is a negative amount. Enter this amount on line A of the enclosed IRS Notice 703 to see if any part of your Sociai Security benefits may be taxable. W H O T O C O N T A C T F O R M O R E I N F O R M A T I O N If you have any questions about the figures shown on this form call SSA at This is a free call and can be used through April 15,1986. If after completing the enclosed Notice 703 you still have questions about how to figure the taxable portion (if any) of your benefits, call IRS at the tolhfree number for your area that is on the back of Notice 703.

F O R M S S A - 1 0 9 9 - S O C I A L S E C U R I T Y B E N E F I T S T A T E M E N T ^ am PART OF YOUR SOCIAL SECURITY BENEFITS AS SHOWN IN BOX 5 MAY BE TAXABLE INCOME FOR 1985.

4 F O R M S S A S O C I A L S E C U R I T Y B E N E F I T S T A T E M E N T ^ am PART OF YOUR SOCIAL SECURITY BENEFITS AS SHOWN IN BOX 5 MAY BE TAXABLE INCOME FOR <1 1 O 2700 Q C BENEFITS USE THE MAY FIGURE BE FROM TAXABLE BOX ON 5 OF YOUR THIS STATEMENT FEDERAL INCOME AND THE TAX ENCLOSED RETURN. NOTICE 703 FROM IRS TO SEE IF ANY PART OF YOUR ^ ^ ^ ALSO SEE GENERAL INFORMATION BELOW. B o x 1. N a m e B o x 3. B e n e fi t s f o r ARTHUR BERL $ Box 4. Benefits Repaid to SSA in 1985 NONE Box 2. Beneficiary's Social Security Number f o r w a s $ B o x 5. N e t B e n e fi t s ( B o x 3 m i n u s B o x 4 ) 1 D E S C R I P T I O N O F A M O U N T I N B O X 3 fl W O U N T S P R I D. B V C H E C K ' O R D I R E C T D E P O S I T $ D E S C R I P T I O N O F A M O U N T I N B O X 4 NONE B E N E F I T S F O R $ B o x 6. A d d r e s s ARTHUR BERL S R R T B K 2 CAMBRIA CR 93M28 Box 7. Claim Number (Use this number if you need to contact SSA.) A

Read This To See If Your Benefits May Be Taxable For 1985, depending on the amount of your income, you may have to Include part of your social security benefits on your Federal Income tax return.

5 Read This To See If Your Benefits May Be Taxable For 1985, depending on the amount of your income, you may have to Include part of your social security benefits on your Federal Income tax return. If your social security and/or SSI (Supplemental Security Income) benefits were your only source of Income for 1985, you probably will not have to file a Federal Income tax return. To see If part of your benefits may be taxable, fill In lines A through E below. Note: If you would file a joint income tax Internal Revenue^ return, and your spouse also received a Form(s) SSA-1099, add your spouse's amounts to yours on lines A, C, and D below. Even If your spouse did not receive a Form(s) SSA-1099, include his or her Income on lines C and D. A Write m the amount from Box 5 of al your Forms SSA (If both you and your spouse received a Form SSA-1099, see the "Note" above.) A If the amount on line A above is zero or less, stop here; none of your benefits are taxable this ye7r B divide the amount on line A above by 2 and write In the result C Add up your pensions, wages. Interest, dividends, and other taxable Income and write in the total.' ' C D Write in any tax-exempt Interest, such as Interest on municipal bonds 0 E Add lines B, C, and D above, and write In the total. Read the information below ^ Part of your social security benefits may be taxable If, for 1985, you were: Single, and line E above Is more than $25,000. Married, and you would file a joint return, and line E above Is more than $32,000; or you would not file a joint return, you did not live with your spouse at any time during the year, and line E above is more than $25.000: or you would not file a joint return, you lived with your spouse for some part of the year, and line E above Is more than zero. If your figures show that part of your benefits may be taxable, see your Federal Incorne Tax Return Instructions under Social Security Benefits." If they do not none of your benefits are taxable this year' unless you exclude Income from sources outside the United States. DO NOT RETURN THIS FORM TO SSA OR IRS For more details, get IRS Publication 915, Tax Information on Social Security Benefits (and Tier 1 Railroad Retirement Benefits), or call the toll-free number on the back of this notice. Note: If your figures show that part of your benefits may be taxable and you received benefits In 1985 that were for 1984, see Publication 915 for rules on a special election you may want to make that may reduce the amount of your taxable benefits.

To Call IRS Toll-Free for Answers to Your Federal Tax Questions, Use Only the Number Listed Below for Your Area If you have questions about w/hether your social security benefits may be taxable for

6 To Call IRS Toll-Free for Answers to Your Federal Tax Questions, Use Only the Number Listed Below for Your Area If you have questions about w/hether your social security benefits may be taxable for 1985, you can call the IRS toll-free number listed below for your area. You pay only local charges for the toll-free call. Please use the number for your area if it is not a long-distance call for you. Otherwise, use the general toll-free number given below. To make sure that IRS employees give courteous answers and correct information to you, a second IRS employee may listen in on the telephone call. However, IRS does not keep a record of your name, address, or social security number. If, instead of calling, you need to write, please address your letter to your IRS District Director for a prompt reply. Make sure you include your social security number when you write. ALABAMA ALASKA Anchorage, Elsewhere in Alaska, call operator and ask for Zenith 3700 ARIZONA Phoenix, ARKANSAS CALIFORNIA Please call the telephone number shown in the white pages of your local telephone directory under U.S. Government, Internal Revenue Service, Federal Tax Assistance. COLORADO Denver, CONNECTICUT DELAWARE Wilmington, DISTRICT OF COLUMBIA Call FLORIDA Jacksonville, GEORGIA Atlanta, HAWAII Oahu, All other islands, IDAHO ILLINOIS Chicago, INDIANA Indianapolis, IOWA Des Moines, KANSAS KENTUCKY LOUISIANA MAINE MARYLAND Baltimore, Montgomery County, Prince George's County, MASSACHUSETTS Boston MICHIGAN Detroit, MINNESOTA Minneapolis, St. Paul, MISSISSIPPI MISSOURI St. Louis, MONTANA NEBRASKA Omaha, NEVADA NEW HAMPSHIRE NEW JERSEY Newark,

NEW MEXICO NEW YORK Bronx, 732-0100 Brooklyn, 596-3770 Buffalo, 855-3955 Manhattan, 732-0100 Nassau, 222-1131 Queens, 596-3770 Rockland County, 997-1510 Staten Island, 732-0100 Suffolk, 724-5000

7 NEW MEXICO NEW YORK Bronx, Brooklyn, Buffalo, Manhattan, Nassau, Queens, Rockland County, Staten Island, Suffolk, Westchester County, NORTH CAROLINA Greensboro, NORTH DAKOTA OHIO Cincinnati, Cleveland OKLAHOMA OREGON Eugene Portland, Salem, PENNSYLVANIA Philadelphia, Pittsburgh, PUERTO RICO San Juan Metro Area, Isia ODD, RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE Nashville, TEXAS Austin, Corpus Christi, Dallas, El Paso, Ft. Worth, Houston, San Antonio, UTAH VERMONT VIRGINIA Bailey's Crossroads, Richmond, WASHINGTON Seattle, WEST VIRGINIA WISCONSIN Milwaukee, WYOMING Note: If there Is no number listed for your specific area, please call Telephone Assistance Services for Deaf Taxpayers Who Have Access to TV / Telephone TTY Equipment. Hours of Operation 8:00 A.M. to 6:45 P.M. EST (Jan. 1-April 15) 8:00 A.M. to 4:30 P.M. EST (April 16-Dec.31), o r Indiana residents, Elsewhere in U.S., including Alaska, Hawaii, Virgin Islands, and Puerto Rico,

Income from U.S. Government Obligations

Income from U.S. Government Obligations Baird s ----------------------------------------------------------------------------------------------------------------------------- --------------- Enclosed is the 2017 Tax Form for your account with