EFTA01222595.pdf

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