Form 1099-G - Certain Government Payments - 2017 Page 3
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8VOID
CORRECTED
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
2017
$
Government
2 State or local income tax
Payments
refunds, credits, or offsets
1099-G
$
Form
PAYER'S federal identification number RECIPIENT'S identification number
3 Box 2 amount is for tax year
4 Federal income tax withheld
Copy 1
$
For State Tax
RECIPIENT'S name
5 RTAA payments
6 Taxable grants
Department
$
$
7 Agriculture payments
8 Check if box 2 is
trade or business
$
Street address (including apt. no.)
income
▶
9 Market gain
$
City or town, state or province, country, and ZIP or foreign postal code
10a
10b
11
State
State identification no.
State income tax withheld
$
Account number (see instructions)
$
1099-G
Form
Department of the Treasury - Internal Revenue Service
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