FORM SSA-1099-SOCIAL SECURITY BENEFIT STATEMENT PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME SEE THE REVERSE FOR MORE INFORMATION 1. Name 2. Beneficiary's Social Security Number Gordon Ferris 130-00-XXXX Box 5. Net Benefits for 2017 (Box 3 min 3. Benefts Paid in 2017 4. Bonefits Repaid to SSA in 2017 $16,000.00 $16,000.00 DESCRIPTION OF AMOUNT IN BOX 3 DESCRIPTION OF AMOUNT IN BOX 4 Paid by check or direct deposit $14,692 Medicare Part B premiums deducted from your benefits $1,308 Medicare Prescription Drug premiums (Part D) deducted from your benefits . Voluntary Federal Income Tax Withholding 7. Address 1932 Calvert Court Your City, State Zip Total Additions Benefits for 2017: $16,000 8. Claim Number Uso thig number if you naod to contact SSA Form SSA-1099-SM (5-2017) DO NOT RETURN THIS FORM TO SSA OR IRS RECTED (if check 2 Date won OMB No. 1545-0238 PAYERS name, street address, city or town, province or state, country, and1 Reportable winnings ZIP or foreign postal code 3,000.00 3 Type of wager RAFFLE 5 Transaction 5/28/2017 4 Federal income tax withhed Form W-2 ORLEANS CASINO 222 RACINE ROAD YOUR CITY, STATE ZIP 750.00 6 Race Gambling 7 Winnings from identical wagers 8 Cashier PAYER'S federal identification number PAYER'S telephone number 9 Winnes taxpayer idenification no 10 Window This information is being furnished to the Internal Revenue Service 130-00-Xxxx 38-600XXXX YOUR PHONE # 11 First LD YS987654 13 Stale/Payer's state idertfcaton no. 14 State winnings 12 Second LD. GORDON FERRIS Street address (including apt. no 1932 CALVERT COURT City or town, province or state, country, and ZiP or foreign postal code YOUR CITY, STATE ZIP YS 316-00-XXXX Copy B Report this income on your federal tax return. If this form shows federal 15 State income tax withheld 16 Local winnings tax withheld in box 4, attach this copy to your returm. 17 Local income tax 18 Name of locality Under penalties of perjury, I declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that I have fumished correctly identify me as the reciplent of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments Form W-2G www.irs.gow/w2g Department of the Treasury-Intemal Revenue Service