Form 1099-G - Certain Government Payments - 2012 Page 3
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1
2
3
4
5
6CORRECTED (if checked)
PAYER’S name, street address, city, state, ZIP code, and telephone no.
1 Unemployment compensation
OMB No. 1545-0120
Certain
2012
$
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 ATAA/RTAA payments
6 Taxable grants
This is important tax
information and is
being furnished to the
$
$
Internal Revenue
Service. If you are
Street address (including apt. no.)
7 Agriculture payments
8 If checked, box 2 is
required to file a return,
trade or business
$
a negligence penalty or
income
▶
other sanction may be
9 Market gain
City, state, and ZIP code
imposed on you if this
$
income is taxable and
the IRS determines that
Account number (see instructions)
10a State
10b State identification no. 11
State income tax withheld
it has not been
$
reported.
1099-G
Form
(keep for your records)
Department of the Treasury - Internal Revenue Service
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