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pdfSSA-1099/1042S
SCREENS FOR
OMB CLEARANCE PACKAGE
PREPARED BY:
OSES/DBSD
JUNE 18, 2009
Title: iRRet Screens for OMB Clearance Package
TABLE OF CONTENTS
1.0
APPLICATION PAGES.........................................................................................................1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
REQUEST AN SSA-1099/1042S FOR TAX INFORMATION ............................................................................................. 1
THIS SERVICE IS CURRENTLY UNAVAILABLE .............................................................................................................. 2
LEGAL ACKNOWLEDGEMENT...................................................................................................................................... 3
PUBLIC AGREEMENT .................................................................................................................................................. 4
GENERAL INFORMATION ABOUT YOU ......................................................................................................................... 5
GENERAL INFORMATION ABOUT THE DECEASED......................................................................................................... 6
PLEASE LOG IN........................................................................................................................................................... 7
PLEASE LOG IN........................................................................................................................................................... 8
CONFIRMATION .......................................................................................................................................................... 9
CONFIRMATION ........................................................................................................................................................ 10
2.0
MESSAGE PAGES ...............................................................................................................11
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
2.15
MSG024.................................................................................................................................................................... 11
MSG025.................................................................................................................................................................... 12
MSG027.................................................................................................................................................................... 13
MSG028.................................................................................................................................................................... 14
MSG030.................................................................................................................................................................... 15
MSG036.................................................................................................................................................................... 16
MSG037.................................................................................................................................................................... 17
MSG045.................................................................................................................................................................... 18
MSG051.................................................................................................................................................................... 19
MSG061.................................................................................................................................................................... 20
MSG062.................................................................................................................................................................... 21
MSG063.................................................................................................................................................................... 22
MSG064.................................................................................................................................................................... 23
MSG065.................................................................................................................................................................... 24
MSG066.................................................................................................................................................................... 25
Prepared by OSES/DBSD
Page i
Title: iRRet Screens for OMB Clearance Package
1.0 APPLICATION PAGES
1.1
REQUEST AN SSA-1099/1042S FOR TAX INFORMATION
Prepared by OSES/DBSD
Page 1
Title: iRRet Screens for OMB Clearance Package
1.2
THIS SERVICE IS CURRENTLY UNAVAILABLE
Prepared by OSES/DBSD
Page 2
Title: iRRet Screens for OMB Clearance Package
1.3
LEGAL ACKNOWLEDGEMENT
Prepared by OSES/DBSD
Page 3
Title: iRRet Screens for OMB Clearance Package
See Revised Public Agreement Page
1.4
PUBLIC AGREEMENT
See Revised Privacy Act Statement
See Revised Paperwork
Reduction Act
Prepared by OSES/DBSD
Page 4
Title: iRRet Screens for OMB Clearance Package
See Revised General Information About
You Page
1.5
GENERAL INFORMATION ABOUT YOU
Prepared by OSES/DBSD
Page 5
Title: iRRet Screens for OMB Clearance Package
1.6
GENERAL INFORMATION ABOUT THE DECEASED
Prepared by OSES/DBSD
Page 6
Title: iRRet Screens for OMB Clearance Package
See Revised Please Log In Page
1.7
PLEASE LOG IN
Prepared by OSES/DBSD
Page 7
Title: iRRet Screens for OMB Clearance Package
1.8
PLEASE LOG IN
Prepared by OSES/DBSD
Page 8
Title: iRRet Screens for OMB Clearance Package
1.9
CONFIRMATION
Prepared by OSES/DBSD
Page 9
Title: iRRet Screens for OMB Clearance Package
1.10 CONFIRMATION
Prepared by OSES/DBSD
Page 10
Title: iRRet Screens for OMB Clearance Package
2.0 MESSAGE PAGES
2.1
MSG024
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.2
MSG025
Prepared by OSES/DBSD
Page 12
Title: iRRet Screens for OMB Clearance Package
2.3
MSG027
Prepared by OSES/DBSD
Page 13
Title: iRRet Screens for OMB Clearance Package
2.4
MSG028
Prepared by OSES/DBSD
Page 14
Title: iRRet Screens for OMB Clearance Package
2.5
MSG030
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.6
MSG036
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.7
MSG037
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.8
MSG045
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.9
MSG051
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.10 MSG061
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.11 MSG062
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.12 MSG063
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.13 MSG064
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Title: iRRet Screens for OMB Clearance Package
2.14 MSG065
Prepared by OSES/DBSD
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Title: iRRet Screens for OMB Clearance Package
2.15 MSG066
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Title: iRRet Screens for OMB Clearance Package
Prepared by OSES/DBSD
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The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 223 and 1633 of the Social Security Act, as amended, authorize us to collect this
information. The information you provide will be used in making a decision on this
claim.
The information you furnish on this form is voluntary. However, providing the
information on this form is an obligation under the terms of your contract, and failure to
provide the information may result in a delay in processing the claim.
We rarely use the information you supply for any purpose other than for determining
eligibility. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the
following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.socialsecurity.gov or at your local
Social Security office.
The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about xxx
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.
il099 Application Screens hots with updated OMB Expiration Date:
Public Agreement Page (eeO03.isp)
~. Public Agreement
\.!f'·
Social SeCUfity provides this website for your c""",,nience,
The PrtvKy Act SllltMlent
SocIal Secuni)' IS allowed to collect the fads on tnlS form under Sedlon 205 o/!he SocIal Secunly
Ad We need!hese fadS 10 quid<1y ldenlify wtro you are and pnMde lhe information you
requested G.ving us !hese facts is vOlunlaf)' However, WIthout them we may not be able to give
you !he Information that you wanl The Soc.al Secunl)' Admrrustrabon WID no! use the InlOIllltIbon for
any other purpose ff you wanllo read more Information on this subject, read The Co!!edjQn and
Use of IIlfOfmatlQ/l from Your AllPlcalloo
This InfOfmation COliedIOfl meets the requirements of 44 U S,C, § 3507, as amended by section 2
of the Paperworl< Reduction Ad 0/ 1995, You do not need to answer these questions unless we
display a wld Office 0/ Management and Budget comol nUmber. The OMS conIrol numl>er for this
foon IS 0960-0583, expiration dale 1213112012 We estimate 1hat It Wlllake abool10 mrnu\es 10
read !he 'nstructions, gather the fads, and answer the questIons, You may send comments on 001'
time estimale above to SSA. 1338 Annex Building, BaRimore, MD 21235-0001 Send ll!!~
comments on our tIm;t ••tlmate to til.. add,...., not the complelad form,
By using lhis website, you agree to ~s "~ahOllS
General Information Page (ee004.jsp)
j~ General Information About You
\,1/
Why do you need ..
replacement SSA·10fi11042S?
m.
Have you heel • "hange of
addr"_ lltet hY not been
reported to SocIal Security?
2
Login Page (ee005.jsp)
~ Please Log In
Please provide the following mlormanon 10 lden!!l'y yourse"" Be sure 10 type yOUf name as ,t is
shown 00 yoor Social Securily Card
'Your Social Securtty Number:
Use your own number even If you
are rece!\lrng benefds as a spouse"
parent or clltld uoder another
'f (WIthout dashes or spaces)
person's number
·YourName:
",rsf MldOIe !nibal (if any), last
Suffix (if any)
I----'-~,--~"----~,~~"-~--,-,--~-"-~-----,-~,- ----"-"---~------~-"-,--"----,---'
other L••t Name (If any):
For example, your name as Shown
on a recent letter from Social
Security or yoor maiden name"
'Your o.te of BIrth:
Month, Day, Yea,
3
| File Type | application/pdf |
| Author | 500267 |
| File Modified | 2009-11-13 |
| File Created | 2009-09-30 |