Form Uia 1920 - Request For Form 1099-G - 2012
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1UIA 1920
Authorized by
State of Michigan
(Rev 02-12)
MCL 421.1, et seq
Department of Energy, Licensing and Regulatory Affairs
U
I
A
NEMPLOYMENT
NSURANCE
GENCY
Reset Form
Request for Form 1099-G
Mail To:
UIA 1099-G
P.O. Box 169
Grand Rapids, Michigan 49501-0169
Fax To: 1-517-636-0427
SSN:
Need Help! Call our Inquiry Line at: 1-866-500-0017 (TTY customers use 1-866-366-0004)
Form 1099-G reports the total taxable unemployment compensation you received for the calendar year. If you want to request a
duplicate copy of a Form 1099-G from either the current or a prior year, fill out only the “current information” in the shaded box
below, including taxable year (total unemployment compensation is not necessary). If you want to request corrections to Form
1099-G for either the current or prior year, fill out both the current and corrected information boxes below.
If you disagree with the total compensation and have had restitution for unemployment benefits or court ordered deductions,
those monies are included as total compensation.
A correction cannot be made for these reasons. Contact the Internal Revenue
Service (IRS) to get specific instructions on how these amounts affect your taxes and how to report them.
Please print (in black ink only) or type information.
CURRENT INFORMATION
CORRECT INFORMATION
Recipient's Identification Number (Social Security Number)
Recipient's Identification Number (Social Security Number)
Recipient's Name
Recipient's Name
Street Address (including apt. no.)
Street Address (including apt. no.)
City, State and ZIP Code
City, State and ZIP Code
Total Unemployment Compensation
Total Unemployment Compensation
$
$
Taxable Year
Taxable Year
Additional Information:
_______________________________________ __________________________________ ____________
Signature
Telephone No.
Date
For UIA Use Only
User ID _______________________________________
Date ____________
LARA is an equal opportunity employer/program.
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