Form 1099-G - Certain Government Payments - 2014 Page 2
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88686
VOID
CORRECTED
OMB No. 1545-0120
PAYER’S name, street address, city or town, state or province, country, ZIP
1 Unemployment compensation
or foreign postal code, and telephone no.
Certain
2014
$
Government
2 State or local income tax
Payments
refunds, credits, or offsets
1099-G
$
Form
Copy A
PAYER’S federal identification number RECIPIENT’S identification number
3 Box 2 amount is for tax year
4 Federal income tax withheld
$
For
Internal Revenue
RECIPIENT’S name
5 RTAA payments
6 Taxable grants
Service Center
$
$
File with Form 1096.
7 Agriculture payments
8 Check if box 2 is
trade or business
For Privacy Act
$
Street address (including apt. no.)
income
▶
and Paperwork
9 Market gain
Reduction Act
$
City or town, state or province, country, and ZIP or foreign postal code
Notice, see the 2014
General
10a
10b
11
State
State identification no.
State income tax withheld
Instructions for
$
Account number (see instructions)
Certain Information
$
Returns.
1099-G
Form
Cat. No. 14438M
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
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