❑ CORRECTED Of checked)

EFTA01222595 Dataset 9 1 pages Download original PDF Download as text
❑ CORRECTED Of checked) 1 Unemployment compensation OMB No. 1545-0120 PAYERS name. street address. city cr town. state cr province, country. ZIP or foreign postal code. and telephone no. 2 State or local income tax refunds. credits. or offsets 2017 Form 1099-G Certain Government Payments PAYERS federal identification number RECIPIENT'S identification number 3 Box 2 amount is for tax year 4 Federal income tax withheid $ 6 Taxable grants $ RECIPIENT'S name Street address onciudirg apt. no.) City or town. state or province. country. and ZIP or foreign postal code S RTAA payments $ 7 Agriculture payments $ 0 Market g in $ 10a Slate 8If checked. box 2 is trade or business ❑ ricome P Account number (see instructions) 0b Slate iciers4cabonno 11 Slate incom waith*, $ $ Copy For Recipient This is important tax information and is being lumshed to the Internal Revenue Service. If you are required to file a return. a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. Form 1099-G (keep for your records) wvewirs.gov/fom11009g Department of the Treasury - Internal Revenue Service EFTA01222595