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De: Arizona DES/UI <notifications@cognitoforms.com>

Fecha: 22 de diciembre de 2021, 11:40:30 a.m. GMT-7
Para: martinalfredofragoso@hotmail.com
Asunto: 1099 Affidavit - Martin Fragoso
Responder-Para: uiclaimdocs@azdes.gov

Arizona DES/UI
1099 Affidavit
Thank you for filling out the form. Your response has been recorded.

Entry Details
Reason for filing this form?
REASON FOR FILING THE FORM (SUB I want to request a 1099-G. I received benefit
SECTION)
payments, but have not yet received a 1099-G

PROGRAM PUA (Pandemic Unemployment Assistance)

Personal Information
NAME OF FILER Martin Fragoso

ADDRESS 2202 E 7th St, Douglas, Arizona 85607

WHO IS COMPLETING THIS FORM? This form is being completed by a ADES

Representative

DEPUTY NAME Jonathan

DEPUTY # D66

PRINT NAME Jonathan Deputy #D66 on behalf of Martin

Fragoso

DATE 12/22/2021

PHONE (520) 585-8209

EMAIL martinalfredofragoso@hotmail.com