Form 1099-G - Certain Government Payments - 2014 Page 4
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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
2014
$
Government
2 State or local income tax
Payments
refunds, credits, or offsets
1099-G
$
Form
Copy B
PAYER’S federal identification number RECIPIENT’S identification number
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
Internal Revenue
7 Agriculture payments
8 If checked, box 2 is
trade or business
Service. If you are
$
Street address (including apt. no.)
income
▶
required to file a return,
9 Market gain
a negligence penalty or
other sanction may be
$
City or town, state or province, country, and ZIP or foreign postal code
imposed on you if this
10a
10b
11
State
State identification no.
State income tax withheld
income is taxable and
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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