Tennessee Department of Labor & Workforce

Development Certain Government Payments 1099G

l
l P O Box 280870
Nashville, TN 37228-0778
Claimant/Job Seeker:
James Smith
Claimant ID Number:
0008001700

James F Smith
1018 Sevierville Rd
Maryville, TN 37804-5024

[] VOID [] CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Unemployment OMB No. 1545-0120
or foreign postal code, and telephone no. compensation
STATE OF TENNESSEE DEPARTMENT OF LABOR & WORKFORCE $ 3930.00
Certain
DEVELOPMENT
312 ROSA L PARKS AVENUE
2 State or local income tax
refunds, credits, or offsets
2019 Government
Payments
NASHVILLE, TN 372431102
$ 0.00 Form 1099-G
PAYER’S federal identification no. RECIPIENT'S identification no. 3 Box 2 amount is for tax 4 Federal income tax Copy 1
626001445 244-94-2272 year withheld
$ 390.00
RECIPIENT’S name 5 RTAA payments 6 Taxable grants For State Tax
Smith James F $0.00 $ 0.00
7 Agriculture payments 8 Check if box 2 is
Department
Street address (including apt. no.) $ 0.00 trade or business
1018 SEVIERVILLE RD income [ ]
9 Market gain
City or town, state or provice, country, and zip or foreign postal code $ 0.00
Maryville TN, 37804-5024
10a State 10b State id no. 11 State income tax
withheld
Account number (see instructions) ------------- ----------------------- $ 0.00
----------------------------

Form 1099-G www.irs.gov/form1099g Department of the Treasury - Internal Revenue Service

[] VOID [] CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Unemployment OMB No. 1545-0120
or foreign postal code, and telephone no. compensation
STATE OF TENNESSEE DEPARTMENT OF LABOR & WORKFORCE $ 3930.00
Certain
DEVELOPMENT
312 ROSA L PARKS AVENUE
2 State or local income tax
refunds, credits, or offsets
2019 Government
Payments
NASHVILLE, TN 372431102
$ 0.00 Form 1099-G
PAYER’S federal identification no. RECIPIENT'S identification no. 3 Box 2 amount is for tax 4 Federal income tax Copy A
626001445 244-94-2272 year withheld
$ 390.00 For
RECIPIENT’S name 5 RTAA payments 6 Taxable grants Internal
Smith James F $0.00 $ 0.00
7 Agriculture payments 8 Check if box 2 is
Revenue
Street address (including apt. no.) $ 0.00 trade or business Service
1018 SEVIERVILLE RD income [ ]
9 Market gain
Center
City or town, state or provice, country, and zip or foreign postal code $ 0.00 File with Form
Maryville TN, 37804-5024 1096.
10a State 10b State id no. 11 State income tax
withheld
For Privacy Act
------------- ----------------------- $ 0.00 and Paperwork
---------------------------- Reduction Act
Notice, see the
2019
General
Instructions for
Certain
Account number (see instructions) Information
Returns.
Form 1099-G www.irs.gov/form1099g Department of the Treasury - Internal Revenue Service

l
1 of 4 EEA9DBA4-217B-4A89-877D-C756BE49CBC0
 [] VOID [] CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Unemployment OMB No. 1545-0120
or foreign postal code, and telephone no. compensation
STATE OF TENNESSEE DEPARTMENT OF LABOR & WORKFORCE $ 3930.00
Certain
DEVELOPMENT
312 ROSA L PARKS AVENUE
2 State or local income tax
refunds, credits, or offsets
2019 Government
Payments
NASHVILLE, TN 372431102
$ 0.00 Form 1099-G
PAYER’S federal identification no. RECIPIENT'S identification no. 3 Box 2 amount is for tax 4 Federal income tax Copy B
626001445 244-94-2272 year withheld For
$ 390.00
Recipient
RECIPIENT’S name 5 RTAA payments 6 Taxable grants
This is important tax
Smith James F $0.00 $ 0.00 information and is being
7 Agriculture payments 8 Check if box 2 is furnished to the Internal
Street address (including apt. no.) $ 0.00 trade or business Revenue Service. If you
1018 SEVIERVILLE RD income [ ] are required to file a
9 Market gain return, a negligence
City or town, state or provice, country, and zip or foreign postal code $ 0.00
penalty or other
Maryville TN, 37804-5024 sanction may be
10a State 10b State id no. 11 State income tax imposed on you if this
withheld income is taxable and
------------- ----------------------- $ 0.00 the IRS determines that
Account number (see instructions) it has not been
---------------------------- reported.

Form 1099-G www.irs.gov/form1099g Department of the Treasury - Internal Revenue Service

2 of 4 EEA9DBA4-217B-4A89-877D-C756BE49CBC0
 [] VOID [ ] CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Unemployment OMB No. 1545-0120
or foreign postal code, and telephone no. compensation
STATE OF TENNESSEE DEPARTMENT OF LABOR & WORKFORCE $ 3930.00
Certain
DEVELOPMENT
312 ROSA L PARKS AVENUE
2 State or local income tax
refunds, credits, or offsets
2019 Government
Payments
NASHVILLE, TN 372431102
$ 0.00 Form 1099-G
PAYER’S federal identification no. RECIPIENT'S identification no. 3 Box 2 amount is for tax 4 Federal income tax Copy 2
626001445 244-94-2272 year withheld
$ 390.00
To be filed with
RECIPIENT’S name 5 RTAA payments 6 Taxable grants recipient's state
Smith James F $0.00 $ 0.00 income tax return,
7 Agriculture payments 8 Check if box 2 is when required.
Street address (including apt. no.) $ 0.00 trade or business
1018 SEVIERVILLE RD income [ ]
9 Market gain
City or town, state or provice, country, and zip or foreign postal code $ 0.00
Maryville TN, 37804-5024
10a State 10b State id no. 11 State income tax
withheld
Account number (see instructions) ------------- ----------------------- $ 0.00
----------------------------

Form 1099-G www.irs.gov/form1099g Department of the Treasury - Internal Revenue Service

3 of 4 EEA9DBA4-217B-4A89-877D-C756BE49CBC0
 [] VOID [ ] CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Unemployment OMB No. 1545-0120
or foreign postal code, and telephone no. compensation
STATE OF TENNESSEE DEPARTMENT OF LABOR & WORKFORCE $ 3930.00
Certain
DEVELOPMENT
312 ROSA L PARKS AVENUE
2 State or local income tax
refunds, credits, or offsets
2019 Government
Payments
NASHVILLE, TN 372431102
$ 0.00 Form 1099-G
PAYER’S federal identification no. RECIPIENT'S identification no. 3 Box 2 amount is for tax 4 Federal income tax Copy C
626001445 244-94-2272 year withheld
$ 390.00
RECIPIENT’S name 5 RTAA payments 6 Taxable grants For Payer
Smith James F $0.00 $ 0.00
7 Agriculture payments 8 Check if box 2 is
Street address (including apt. no.) $ 0.00 trade or business For Privacy Act and
1018 SEVIERVILLE RD income [ ] Paperwork
9 Market gain Reduction Act
City or town, state or provice, country, and zip or foreign postal code $ 0.00 Notice, see the 2019
Maryville TN, 37804-5024 General
10a State 10b State id no. 11 State income tax Instructions for
withheld Certain Information
Account number (see instructions) ------------- ----------------------- $ 0.00 Returns.
----------------------------

Form 1099-G www.irs.gov/form1099g Department of the Treasury - Internal Revenue Service

4 of 4 EEA9DBA4-217B-4A89-877D-C756BE49CBC0