1099-g_form | Document Preview

VOID

CORRECTED

PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.

, , , , ,

1	Unemployment compensation
$

2	State or local income tax refunds, credits, or offsets
$

OMB No. 1545-0120 Form 1099-G (Rev. January 2024)

For calendar year

2024

Certain
Government Payments

PAYER'S TIN

RECIPIENT'S TIN

3	Box 2 amount is for tax year
$

4	Federal income tax withheld
$

RECIPIENT'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

, , ,

5	RTAA payments
$

6	Taxable grants
$

7	Agriculture payments
$

8 Check if box 2 is trade or business income. . checkbox

9	Market gain
$

For State Tax Department

Account number (see instructions)

10a	State

10b	State identification no

11	State income tax withheld
$