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1099-G
Step
1
of
4
25%
Email
*
General Information
Tax Year
2022
2021
2020
Payer's Information
Payer's TIN
Payer's Address
PAYER'S name, street address, city or town, state or province, country, ZIP, Phone number
Recipient’s Information
Recipient’s Name
Recipient’s TIN
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Recipient’s Address
Apt/Ste No.
Address (Number and Street)
City, State, Country, Zip Code
Certain Government Payments
Account Number
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
YYYY slash MM slash DD
4. Federal income tax withheld
5. RTAA Payments
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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)
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
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?
Yes
No
10a. State (Line 2)
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
10b. State Identification Number (Line 2)
11. State Income Tax Withheld (Line 2)
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1099-G
Price:
Payment Method
PayPal Checkout
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
Security Code
Cardholder Name
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