Form 1099-G - Certain Government Payments - 2016 Page 4
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7
8CORRECTED (if checked)
PAYER'S name, street address, city or town, state or province, country, ZIP
1 Unemployment compensation
OMB No. 1545-0120
or foreign postal code, and telephone no.
Certain
2018
$
Government
2 State or local income tax
Payments
refunds, credits, or offsets
1099-G
$
Form
Copy B
PAYER'S TIN
RECIPIENT'S TIN
3 Box 2 amount is for tax year
4 Federal income tax withheld
$
For Recipient
RECIPIENT'S name
5 RTAA payments
6 Taxable grants
This is important tax
$
$
information and is
being furnished to the
7 Agriculture payments
8 If checked, box 2 is
IRS. If you are required
trade or business
$
Street address (including apt. no.)
to file a return, a
income
▶
negligence penalty or
9 Market gain
other sanction may be
$
imposed on you if this
City or town, state or province, country, and ZIP or foreign postal code
income is taxable and
10b State identification no. 11
State income tax withheld
10a State
the IRS determines that
$
Account number (see instructions)
it has not been
reported.
$
1099-G
Form
(keep for your records)
Department of the Treasury - Internal Revenue Service
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