report of contact - social security administration · form ssa-5002 (8-1981) ef (12-2004). report...
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Form SSA-5002 (8-1981) ef (12-2004)
REPORT OF CONTACT(Use ink or typewriter)
ACCOUNT NUMBER AND SYMBOL
TO:
NE MAT SE GL WN MAM
ODO OIO DDS
NAME OF WAGE EARNER OR SE PERSON
PERSON(S) CONTACTED AND ADDRESSES WE OR SE PERSON OTHER (Specify)
CONTACT MADE:
DO BO CS HOME PHONE: OTHER
DATE OF CONTACT
SUBJECT
SIGNATURE
DISTRICT OFFICE (Name, Address & Code)CR FR SR
CLAIMS CLERICAL
OTHER (Specify)
DATE OF REPORT
PAGE OF
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SSA-1099/SSA-1042S Inquiry
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Tax liable (Circle One): YES NO
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Request number (Circle One): 1st 2nd
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PD benefits paidFP facility of payment (203(i))
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ES supplemental medical insuranceSI supplemental security income
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WC workers compensation offsetLS lump-sum death payment
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AF attorney feesPY nontaxable benefits from prior year
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OP overpayment recovery by withholdingTX alien tax withheld (1042S only)
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DR direct remittance TR alien tax refund (1042S only)
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RC returned checkTE alien tax withheld at wrong rate (1042S only)
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S4 payment made for earlier yearsMS miscellaneous
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VT voluntary tax withheld
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Description of inquiry
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Name of Inquirer: Daytime telephone number: ( )
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