Unemployment Insurance Division 
                                    P0 Box 621 
                     Albany,  NY 12201-0621 
                                                 
                    Request for Income Tax Withholding Report (1099G) 
 
 Your Social Security Account Number:      -     -              
 
 NAME 
 
 First:                                                                  
 
 Middle Initial:     
 
 Last:                                                                   
 
 ADDRESS 
 
 Street:                                                                  
 
 City:                                                                    
 
 State:                                                                   
 
 Zip Code:           -              
 
 Telephone  Number, including area code: (       )             -        ext:              
 
 Calendar Year Being Requested:               
 
 This form may be used to request  a duplicate 1099G Statement for Recipients of Certain 
 Government Payments 
 
 Print and Mail the completed form to the address shown above. 
 
 IA  1099.1 (12/20)