CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-0120 1 Unemployment compensation

$

State or local income tax

refunds, credits, or offsets

2

$

PAYER’S Federal identification number RECIPIENT’S identification number 3 Box 2 amount is for tax year 4 Federal income tax withheld

$

RECIPIENT’S name 6 Taxable grants

$

8 Check if box 2 is

trade or business

income 

Street address (including apt. no.) 7 Agriculture payments

$

City, state, and ZIP code

Account number (optional)

Form 1099-G Department of the Treasury - Internal Revenue Service

8686 VOID

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Cat. No. 14438M

Form 1099-G

Certain

Government

Payments

5

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

2004
CORRECTED (if checked)

PAYER’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-0120 1 Unemployment compensation

Certain

Government

Payments

$

State or local income tax

refunds, credits, or offsets

2

$

PAYER’S Federal identification number RECIPIENT’S identification number 3 Box 2 amount is for tax year 4 Federal income tax withheld

$

RECIPIENT’S name 6 Taxable grants

$

Street address (including apt. no.) 7 Agriculture payments

$

City, state, and ZIP code

Account number (optional)

Form 1099-G Department of the Treasury - Internal Revenue Service

Copy B

This is important tax

information and is

being furnished to the

Internal Revenue

Service. 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.

(keep for your records)

For Recipient

Form 1099-G

5

8 Box 2 is trade or

business income 

2004
Instructions for Recipient

Box 1. Shows the total unemployment compensation paid to

you this year. Report this amount as income on the

unemployment compensation line of your income tax return. If

you expect to receive these benefits in the future, you can ask

the payer to withhold Federal income tax from each payment.

Or, you can make estimated tax payments using Form 1040-ES,

Estimated Tax for Individuals.

Box 2. Shows refunds, credits, or offsets of state or local

income tax you received. It may be taxable to you if you

deducted the state or local income tax paid as an itemized

deduction on your Federal income tax return. Even if you did not

receive the amount shown, for example, because it was credited

to your state or local estimated tax, it is still taxable if it was

deducted. If you received interest on this amount, report it as

interest income on your tax return. See the instructions for your

tax return.

Box 6. Shows taxable grants you received from a Federal, state,

or local government.

Box 7. Shows Department of Agriculture payments that are

taxable to you. If the payer shown is anyone other than the

Department of Agriculture, it means the payer has received a

payment, as a nominee, that is taxable to you. This may

represent the entire agricultural subsidy payment received on

your behalf by the nominee, or it may be your pro rata share of

the original payment. See Pub. 225, Farmer’s Tax Guide, and

the Instructions for Schedule F, Profit or Loss From Farming, Box 3. for information about where to report this income. Identifies the tax year for which the refunds, credits, or

offsets shown in box 2 were made. If there is no entry in this

box, the refund is for 2003 taxes.

Box 4. Shows backup withholding or withholding you requested

on unemployment compensation, Commodity Credit Corporation

loans, or certain crop disaster payments. Generally, a payer

must backup withhold on certain payments at a 28% rate if you

Box 8. If this box is checked, the refunds, credits, or offsets in

box 2 are attributable to an income tax that applies exclusively

to income from a trade or business and is not a tax of general

application. If taxable, report the amount in box 2 on Schedule

C, C-EZ, or F (Form 1040), as appropriate.

Box 5. Reserved.

did not give your taxpayer identification number (TIN) or did not

furnish the correct TIN to the payer. See Form W-9, Request for

Taxpayer Identification Number and Certification, for information

on backup withholding. Include this amount on your income

tax return as tax withheld.
CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-0120 1 Unemployment compensation

Certain

Government

Payments

$

State or local income tax

refunds, credits, or offsets

2

$

PAYER’S Federal identification number RECIPIENT’S identification number 3 Box 2 amount is for tax year 4 Federal income tax withheld

$

RECIPIENT’S name 6 Taxable grants

$

Street address (including apt. no.) 7 Agriculture payments

$

City, state, and ZIP code

Account number (optional)

Form 1099-G Department of the Treasury - Internal Revenue Service

VOID

Copy C

For Payer

Form 1099-G

5

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

8 Check if box 2 is

trade or business

income 

2004
Instructions for Payers

General and specific form instructions are provided as

separate products. The products you should use to complete

Form 1099-G are the 2004 General Instructions for Forms

1099, 1098, 5498, and W-G, and the separate specific

instructions, 2004 Instructions for Form 1099-G. A chart in

the general instructions gives a quick guide to which form

must be filed to report a particular payment. To order these

instructions and additional forms, call 1-800-TAX-FORM

(1-800-829-3676).

Due dates. Furnish Copy B of this form to the recipient by

January 31, 2005.

File Copy A of this form with the IRS by February 28, 2005.

If you file electronically, the due date is March 31, 2005.

Caution: Because paper forms are scanned during

processing, you cannot file Forms 1096, 1098, 1099 or 5498

that you download and print from the IRS website.