CORRECTED (if checked)
1
Unemployment compensation  OMB No. 1545-0120
Certain
$
Government
2
State or local income tax
2013
Payments
City
refunds, credits, or offsets
Telephone no.
$
Form
 1099-G
PAYER’S federal identification number
RECIPIENT’S identification number
3
Box 2 amount is for tax year
4
Federal income tax withheld
Copy B
$
For Recipient
RECIPIENT’S name
5
ATAA payments
6
Taxable energy grants
This is important tax
information and is
$
$
being furnished to the
Street address (including apt. no.)
7
Agricultural payments
8
trade or business
required to file a return.
Apartment no.
$
income
G
a negligence penalty or
City
9
Market gain
other sanction may be
imposed on you if this
$
income is taxable and
Account number (see instructions)
10a
State
10b
State identification no.
11
State income tax withheld
the IRS determines that
it has not been
reported.
Form 
1099-G
(keep for your records)
Department of the Treasury - Internal Revenue Service
State       ZIP Code
State        ZIP Code
Payer’s Name
PAYER’S INFORMATION
Street address (including apt. no.)
Street address line 2
Check if box 2 is
Service. If you are
----------------Page (0) Break----------------