Form 1099-G - Certain Government Payments - 2012 Page 5
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2
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6VOID
CORRECTED
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
PAYER’S federal identification number RECIPIENT’S identification number
3 Box 2 amount is for tax year
4 Federal income tax withheld
Copy C
$
For Payer
RECIPIENT’S name
5 ATAA/RTAA payments
6 Taxable grants
For Privacy Act
$
$
and Paperwork
Street address (including apt. no.)
7 Agriculture payments
8 Check if box 2 is
Reduction Act
trade or business
$
Notice, see the 2012
income
▶
General
9 Market gain
City, state, and ZIP code
Instructions for
$
Certain Information
Account number (see instructions)
10a State
10b State identification no. 11
State income tax withheld
Returns.
$
1099-G
Form
Department of the Treasury - Internal Revenue Service
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