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 (see instructions)

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 2011

General

Instructions for

Certain Information

Returns.

ATAA/RTAA payments

$

2011

9 Market gain

$

10a State 10b State identification no. 11 State income tax withheld

$
CORRECTED (if checked)

PAYER’S name, street address, city, state, ZIP code, and telephone no.

Certain

Government

Payments

PAYER’S federal identification number RECIPIENT’S identification number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

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

1 Unemployment compensation OMB No. 1545-0120

$

State or local income tax

refunds, credits, or offsets

2

$

Box 2 amount is for tax year 4 Federal income tax withheld

$

6 Taxable grants

$

8 If checked, box 2 is

trade or business

income 

7 Agriculture payments

$

Form 1099-G

5 ATAA/RTAA payments

$

2011

9 Market gain

$

10a State 10b State identification no. 11 State income tax withheld

3

$
Instructions for Recipient

Account number. May show an account or other unique number the payer

has assigned to distinguish your account.

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 on Schedule A (Form 1040). 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,

you should receive Form 1099-INT for the interest. However, the payer may

include interest of less than $600 in the blank box next to Box 9 on Form

1099-G. Regardless of whether the interest is reported to you, report it as

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

Box 6. Shows taxable grants you received from a federal, state, or local

government.

Box 7. Shows your taxable Department of Agriculture payments. 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 and the Instructions for Schedule F (Form 1040) for information about

where to report this income. Partnerships, see Form 8825 for how to report.

Box 3. Identifies the tax year for which the box 2 refunds, credits, or offsets

shown were made. If there is no entry in this box, the refund is for 2010 taxes.

Box 4. Shows backup withholding or withholding you requested on

unemployment compensation, Commodity Credit Corporation (CCC) loans, or

certain crop disaster payments. Generally, a payer must backup withhold on

certain payments if you did not give your taxpayer identification number to the

payer. See Form W-9 for information on backup withholding. Include this

amount on your income tax return as tax withheld.

Box 8. If this box is checked, the amount in box 2 is 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 or

F (Form 1040), as appropriate.

Box 5. Shows alternative trade adjustment assistance (ATAA) and/or

reemployment trade adjustment assistance (RTAA) payments you received.

Include on Form 1040 on the “Other income” line. See the Form 1040

instructions.

Box 1. Shows the total unemployment compensation paid to you this year.

Combine the box 1 amounts from all Forms 1099-G and report the total as

income on the unemployment compensation line of your tax return. Except as

explained below, this is your taxable amount. If you are married filing jointly,

each spouse must figure his or her taxable amount separately. 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.

For details, see Form 1040-ES. If you made contributions to a governmental

unemployment compensation program or to a governmental paid family leave

program and received a payment from that program, the payer must issue a

separate Form 1099-G to report this amount to you. If you itemize deductions,

you may deduct your contributions on Schedule A (Form 1040) as taxes paid.

If you do not itemize, you only need to include in income the amount that is in

excess of your contributions.

Box 9. Shows market gain on CCC loans whether repaid using cash or CCC

certificates. See the Instructions for Schedule F (Form 1040).

Boxes 10a–11. State income tax withheld reporting boxes.
CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no.

Certain

Government

Payments

PAYER’S federal identification number RECIPIENT’S identification number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

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

VOID

Copy C

For Payer

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2011 General

Instructions for

Certain Information

Returns.

1 Unemployment compensation OMB No. 1545-0120

$

State or local income tax

refunds, credits, or offsets

2

$

Box 2 amount is for tax year 4 Federal income tax withheld

$

6 Taxable grants

$

8 Check if box 2 is

trade or business

income 

7 Agriculture payments

$

Form 1099-G

5 ATAA/RTAA payments

$

2011

9 Market gain

$

10a State 10b State identification no. 11 State income tax withheld

3

$
Instructions for Payer

General and specific form instructions are provided as

separate products. The products you should use to

complete Form 1099-G are the 2011 General

Instructions for Certain Information Returns and the

2011 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, visit IRS.gov or

call 1-800-TAX-FORM (1-800-829-3676).

Due dates. Furnish Copy B of this form to the

recipient by January 31, 2012.

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

2012. If you file electronically, the due date is

April 2, 2012. To file electronically, you must have

software that generates a file according to the

specifications in Pub. 1220, Specifications for Filing

Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and

W-2G Electronically. IRS does not provide a fill-in form

option.

Caution: Because paper forms are scanned during

processing, you cannot file with the IRS Forms 1096,

1097, 1098, 1099, 3921, 3922, or 5498 that you print

from the IRS website.

Need help? If you have questions about reporting on

Form 1099-G, call the information reporting customer

service site toll free at 1-866-455-7438 or

304-263-8700 (not toll free). For TTY/TDD equipment,

call 304-579-4827 (not toll free). The hours of operation

are Monday through Friday from 8:30 a.m. to 4:30

p.m., Eastern time.