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Tax Year

Payer's Information

Payer's Address

Recipient's Information

Recipient’s Address

Certain Government Payments

2nd TIN not.

1. Unemployment compensation

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

3. Enter which tax year field 2 is for

4. Federal income tax withheld

5. RTAA Payments

6. Taxable grants

7. Agriculture payments

8. Check this box if field 2 is trade or business income

9. Market gain

10a. State (Line 1)

10b. State Identification Number (Line 1)

11. State Income Tax Withheld (Line 1)

Do you wish to enter a tax income withheld for a second state?

Email Information

Insert the e-mail address to which you want to receive your 1099-G form form.

Your Email Address *