Request for 1099-G Review
This form should be used to request a review of your 1099-G tax form for calendar year 2020, should you
disagree with it. The New York State Department of Labor will review your 1099-G and will either mail an
amended 1099-G to you, or a letter of explanation in response to your inquiry.
Please print clearly
Last Name: First Name: MI:
Address:
City: State: Zip Code:
Social Security Number (Full SSN Required):
Please check all that apply to you from the following options:
I disagree with the amount included in BOX 1 (Please explain):
I disagree with the amount included in BOX 2 (Please explain):
I disagree with the amount of either the State and/or Federal taxes withheld (Please explain):
The personal information displayed on the 1099G is not mine, but it was incorrectly sent to my mailing
address
The form shows my information, but I did NOT file for any benefits in 2020
Other/ Please explain:
Please submit this completed form to the New York State Department of Labor using one of the
following methods:
Mail to: New York State Department of Labor, PO Box 15130, Albany, NY 12212-5130
Fax to: 518-457-9378
Online: Log in at www.labor.ny.gov/signin. Select “Go to My Inbox” and then “Compose New.” Select
“Request For 1099-G Review” for the subject line. Compose your message. Select "Attach File" and
upload a digital copy of this completed form. Then select “Send”.
LO1099RQ (12/20)
