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.

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