Form SSA-1042S, Social Security Benefit Statement Completed Form Examples and Samples
View clear, filled-out examples of Form SSA-1042S, the Social Security Benefit Statement for non-resident aliens. Our samples help you understand how to read your statement, including gross benefits, repayments, and federal tax withheld.
Form SSA-1042S Example – Non-Resident Alien with Treaty Benefits
How this form was filled:
This is a sample Form SSA-1042S for a Canadian resident receiving U.S. Social Security benefits for the 2025 tax year. It shows the total gross benefits, a repayment made during the year, and the resulting net benefits. Importantly, it reflects $0 in U.S. federal income tax withheld, a common scenario for residents of countries with a tax treaty with the United States, like Canada.
Information used to fill out the document:
- Recipient's Name: Maria Garcia
- Recipient's Address: 123 Maple Avenue, Toronto, ON M5H 2N2, Canada
- Social Security Claim Number: 123-45-6789A
- Tax Year: 2025
- Gross Benefits Paid (Box 2): $18,500.00
- Benefits Repaid (Box 3a): $500.00
- Net Benefits for 2025 (Box 3b): $18,000.00
- U.S. Federal Income Tax Withheld (Box 4): $0.00
- Description of Benefits (Box 5): Social Security Retirement Benefits
What this filled form sample shows:
- Clearly shows the **annual gross and net benefits** paid to the non-resident alien.
- Illustrates a case with **$0 federal tax withheld**, demonstrating the effect of a tax treaty.
- Includes the recipient's foreign address and unique Social Security claim number.
- Specifies the correct **tax year (2025)** for a statement issued in early 2026.
Form specifications and details:
| Form Number: | SSA-1042S |
| Form Name: | Social Security Benefit Statement |
| Use Case: | Non-resident alien (Canadian resident) receiving retirement benefits with a tax treaty exemption. |
| Issued By: | Social Security Administration (SSA) |
| Purpose: | Reports Social Security benefits paid to non-resident aliens for U.S. tax purposes. |
Created: January 29, 2026 07:31 AM
