CORRECTED

PAYER’S name, street address, city, state, and ZIP code 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 5 6 Taxable grants

$

8 The amount in box 2

applies to income from a

trade or business ©

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

Copy A

File with Form 1096.

For Paperwork

Reduction Act

Notice and

instructions for

completing this form,

see Instructions for

Forms 1099, 1098,

5498, and W-2G.

Do NOT Cut or Separate Forms on This Page

Cat. No. 14438M

For

Internal Revenue

Service Center

Form 1099-G

96
CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code 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 5 6 Taxable grants

$

8 The amount in box 2

applies to income from a

trade or business ©

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

96
Instructions for Recipient

Box 1.—Shows the total unemployment compensation paid to

you this year. This amount is taxable income to you. For details,

see the instructions for your Federal income tax return. If you

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

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. If there is an entry in this box, it may

be taxable to you if you deducted the 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 estimated tax, it is still taxable if it was deducted. Any

interest received on this must be included as interest income on

your return. See the instructions for your tax return.

Box 6.—Shows the amount of taxable grants you received from

the Federal, state, or local government.

Box 7.—Shows the amount of 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 (Form 1040), Profit or Loss From

Farming, for information about where to report this income.

Box 3.—Identifies the tax year for which the refund, credit, or

offset shown in box 2 was made. If there is no entry in this box,

the refund is for 1995 taxes.

Box 4.—Shows backup withholding. For example, persons not

furnishing their taxpayer identification number to the payer

become subject to backup withholding at a 31% rate on certain

payments. See Form W-9, Request for Taxpayer Identification

Number and Certification, for information on backup withholding.

Include this on your income tax return as tax withheld.

Box 8.—If this box is checked, the refund, credit, or offset 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. The amount, if taxable, should not be reported on

page 1 of Form 1040, but should be reported on Schedule C,

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

PAYER’S name, street address, city, state, and ZIP code 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

$

8 The amount in box 2

applies to income from a

trade or business ©

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

For Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

5

Form 1099-G

96
Payers, Please Note—

Specific information needed to complete this form and other

forms in the 1099 series is given in the 1996 Instructions for

Forms 1099, 1098, 5498, and W-2G. A chart in those

instructions gives a quick guide to which form must be filed

to report a particular payment. You can order those

instructions and additional forms by calling 1-800-TAX-FORM

(1-800-829-3676).

Furnish Copy B of this form to the recipient by January 31,

1997.

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

1997.

Printed on recycled paper