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    Form 1099G

    Uploaded by

    ghettoewok

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form 1099G

    Uploaded by

    ghettoewok
    3 views1 page

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    © © All Rights Reserved

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    3 views1 page

    Form 1099G

    Uploaded by

    ghettoewok

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    © All Rights Reserved
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    4/16/22, 11:40 AM Form 1099G

    Form 1099G
    This is important tax information and is being furnished to the IRS. If you are required to file a return, a negligence penalty or other sanction may
    be imposed on you if this income is taxable and the IRS determines that it has not been reported.

    View Form 1099G instructions.

    2021 Form 1099G — Certain Government Payments


    Copy B for Recipient

    OMB No.1454-0120

    Employment Development Department


    Unemployment Insurance Integrity and Accounting
    Division – MIC 16A
    P.O. Box 2408
    Rancho Cordova, CA 95741-2408
    Payer’s Federal ID No. 94-2650401

    Recipient's Name
    EVAN A AMACKER
    13921 WILLIAMS WAY
    WHITTIER, CA 90602-2645

    Social Security Number


    XXX-XX-4851

    Table A

    1. Unemployment Compensation (UC) 2. State or Local $0.00 4. Federal Income Tax $0.00
    Income Tax Withheld
    $16,200.00 Refunds, Credits,
    or Offsets
    Type of UC Payments

    UI $16,200.00
    DUA $0.00 3. Box 2 Amount is for Tax Year
    PUA $0.00 (a) 2021 Benefits $0.00
    DI $0.00 Repaid
    (b) Prior Year(s) $0.00
    Benefits Repaid

    Table B

    1. Unemployment Compensation Paid 2. State or Local $0.00 4. Federal Income Tax $0.00
    Family Leave (UC-PFL) Income Tax Withheld
    Refunds, Credits,
    $0.00
    or Offsets
    PFL Payments $0.00

    3. Box 2 Amount is for Tax Year


    (a) 2021 Benefits $0.00
    Repaid
    (b) Prior Year(s) $0.00
    Benefits Repaid 2
    If you disagree with the amounts shown in Table A or Table B, call the 1099G customer service line at 1-866-401-2849. Customer service
    representatives are available Monday through Friday from 8 a.m. to 5 p.m. General information is available 24 hours a day, 7 days a week through
    the automated system.

    https://uio.edd.ca.gov/UIO/Pages/ExternalUser/ClaimantAccountManagement/Display1099GForms.aspx 1/1

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