New York State Department of Labor 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 Mailthe completed form to the address shown above. 
 
IA 1099.1 (2-04)