Form 1099g - Request For Income Tax Withholding Report

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New York State Department of Labor Unemployment Insurance Division
P0 Box 621
Albany, NY 12201-0621
Request for Income Tax Withholding Report (1099G)
Your Social Security Account Number: __ __ __ - __ __ - __ __ __ __
NAME
First: ___________________________________________________________________
Middle Initial: ___
Last: ___________________________________________________________________
ADDRESS
Street:___________________________________________________________________
City: ____________________________________________________________________
State: __________________________________________________________________
Zip Code: __ __ __ __ __ - __ __ __ __
Telephone Number, including area code: ( __ __ __ ) __ __ __ - __ __ __ __ ext: __ __ __ __
Calendar Year Being Requested: __ __ __ __
This form may be used to request a duplicate 1099G Statement for Recipients of Certain
Government Payments
Print and Mail the completed form to the address shown above.
IA 1099.1 (2-04)

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