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PAYER’S name, street address, city, state, and ZIP code 1 Unemployment compensation] OMB No. 1545-0120
$ Certain
2 Sisleovloca 7 19) Government
fe or local income tax
refunds Payments
Statement for
$ Recipients of
PAYER’S Federal identification number ] RECIPIENT'S identification number | 3 Refunds for tax year 4 Federal income tax withheld Copy c
$ For Payer
RECIPIENT'S name ' Discharge of indebtedness | 6 Taxable grants
For Paperwork
$ $ Reduction Act
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City, state, and ZIP code Y f/f Instructions for
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Form 1099-G Department of the Treasury - Internal Revenue Service

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PAYER'S name, street address, city, state, and ZIP code 1 Unemployment compensation] OMB No. 1545-0120
$ Certain
2 State or local income tax 19 Government
refunds Payments
Statement for
$ Recipients of
PAYER’S Federal identification number | RECIPIENT'S identification number | 3 Refundis for tax year ‘4 Federal income tax withheld Copy C
$
r Payer
RECIPIENT'S name 5 Discharge of indebtedness | 6 Taxable grants For Paye
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City, st ZIP form, see
ity, state, and ZIP code Instructions for

Forms 1099, 1098,

‘Account number (optional)

5498, and W-2G.

Form 1099-G

Department of the Treasury - Internal Revenue Service

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PAYER'S name, street address, city, state, and ZIP code 1 Unemployment compensation] OMB No. 1545-0120
$ Certain
2 Sate oa a 19 Government
State or local income tax Payments
Statement for
$ Recipients of
PAYER’S Federal identification number ] RECIPIENT'S identification number | 3 Refundis for tax year ‘4 Federal income tax withheld Copy C
§ For Payer
RECIPIENT'S name '5 Discharge of indebtedness | 6 Taxable grants
For Paperwork
$ $ Reduction Act
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foimcome fromatradeor -} completing this
Yj form, see

City, state, and ZIP code

Instructions for
Forms 1099, 1098,

‘Account number (optional)

5498, and W-2G.

Form 1099-G

Department of the Treasury - Internal Revenue Service


Instructions for Recipient

Box 1.—Shows the total unemployment compensation paid to
you this year by the payer. This amount Is taxable income to you.
For more information, see the instructions for your Federal
income tax return.

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. See the instructions
for Form 1040 or 1040A/1040E2Z for more information.

Box 3.—Identifies the tax year for which the refund shown in Box
2 was made. If there 1s no entry in this box, the refund is for 1989
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 20% 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 5.—Shows your indebtedness to a Federal government
agency that was discharged this year as no longer collectible. This

Instructions for Recipient

Box 1.—Shows the total unemployment compensation paid to
you this year by the payer. This amount is taxable income to you.
For more information, see the instructions for your Federal
income tax return.
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. See the instructions
for Form 1040 or 1040A/1040E2Z for more information.
Box 3.—Identifies the tax year for which the refund shown in Box
2was made. If there 1s no entry in this box, the refund :s for 1989
Xes.
Box 4.—Shows backup withholding. For example, persons not
furnishing their taxpayer identification number to the payer
become subject to backup withholding at a 20% 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 5.—Shows your indebtedness to a Federal government
agency that was discharged this year as no longer collectible. This

Instructions for Recipient

Box 1.—Shows the total unemployment compensation paid to
you this year by the payer. This amount is taxable income to you.
For more information, see the instructions for your Federal
income tax return.

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. See the instructions
for Form 1040 or 1040A/1040EZ for more information.

Box 3.—/dentifies the tax year for which the refund shown in Box
2 was made. If there is no entry in this box, the refund is for 1989
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 20% 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 5.—Shows your indebtedness to a Federal government
agency that was discharged this year as no longer collectible. This

debt generally becomes taxable income to you at the time the
debt is discharged, However, there are exceptions to this
rule—for example, if you are insolvent or have declared
bankruptcy. See Publication 908, Bankruptcy and Other Debt
Cancellation, for additional information.

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 Publication 225, Farmer's Tax Guide, and
the instructions for Schedule F (Form 1040), Farm Income and
Expenses, for information about where to report this income.

Box 8.—!f this box is checked, the refund, credit, or offset in Box
2 1s attributable to an income tax that applies exclusively to
Income from a trade or business and 1s not a tax of general
application. The amount, if taxable, should not be reported on
page one of Form 1040, but should be reported on Schedule C

or F (Form 1040), as appropriate.

debt generally becomes taxable income to you at the time the
debt Is discharged, However, there are exceptions to this
rule—for example, if you are insolvent or have declared
bankruptcy. See Publication 908, Bankruptcy and Other Debt
Cancellation, for additional information.

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 1s 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 Publication 225, Farmer's Tax Guide, and
the instructions for Schedule F (Form 1040), Farm Income and
Expenses, for information about where to report this income.

Box 8.—If this box 1s checked, the refund, credit, or offset in Box
2s 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 one of Form 1040, but should be reported on Schedule C

or F (Form 1040), as appropriate.

debt generally becomes taxable income to you at the time the
debt is discharged, However, there are exceptions to this
rule—for example, if you are insolvent or have declared
bankruptcy. See Publication 908, Bankruptcy and Other Debt
Cancellation, for additional information.

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 1s 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 Publication 225, Farmer's Tax Guide, and
the instructions for Schedule F (Form 1040), Farm Income and
Expenses, for information about where to report this income.

Box 8.—If this box is checked, the refund, credit, or offset in Box
21s attributable to an income tax that applies exclusively to
income from a trade or business and !s not a tax of general
application. The amount, if taxable, should not be reported on
page one of Form 1040, but should be reported on Schedule C

or F (Form 1040), as appropriate.


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(7 CORRECTED

‘Type or machine print PAYER’S name, street address, city, state, and ZIP code

1 Unemployment compensation

OMB No. 1545-0120

‘Account number (optional)

Form 1099-G

$ 1 Certain
2 State or ocalincomet Government
State or ocalincome tax Payments
Statement for
$ Recipients of
PAYER'S Federal identification number] RECIPIENT'S identification number — | 3 Refund is fortax year(YYVY) | 4 Federal income tax withheld Copy A
$ For Internal
‘Type or machine print RECIPIENT'S name 5 Discharge of indebtedness 6 Taxable grants Revenue
Service Center
$ $ For Paperwork
i Reduction Act
8 The amount in Box 2 applies i
‘Street address 7 Agreubure payments toincome from a trade or Notice and
business > instructions for
City, state, and ZIP code completing this
form, see

Instructions for
Forms 1099, 1098,
5498, and W-2G.

Department of the Treasury - Internal Revenue Service

Do NOT Cut or Separate Forms on This Page

&b8b O voip (J CORRECTED

Type or machine print PAYER’S name, street address, city, state, and ZIP code | 1 Unemployment compensation] OMB No. 1545-0120
$ 4990 Certain
2 State or local income tax Government
funds Payments

renin Statement for y
$ Recipients of

PAYER'S Federal identification number] RECIPIENT'S identification number | 3 Refundis for tax year (YYVY) | 4 Federalincome tax withheld Copy A
$ For Internal
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Service Center
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reer aceress Agneulture payme to ncome from a trade or ___, Notice and
business OO] instructions for
City, state, and ZIP code y completing this
form, see
Instructions for
Account number (optional) Forms 1099, 1098,
5498, and W-2G.
Form 1099-G Department of the Treasury - Internal Revenue Service

Do NOT Cut or Separate Forms on This Page

&b8b (voip [(]CORRECTED

‘Type or machine print PAYER'S name, street address, city, state, and ZIP code | 1 Unemployment compensation] OMB No. 1545-0120
$ 1990 Certain
2 State or local income tax Government
funds Payments

reruns Statement for y
$ Recipients of
PAYER’ Federal identification number | RECIPIENT'S identification number | 3 Refund is for tax year(YYYY) | 4 Federal income tax withheld Copy A
$ For Internal
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Service Center
$ $ For Paperwork
- Reduction Act
2 "

Strestaddress 7 Rariculture payments 8 The amount in Box 2 applies Notice and
. >I] _ instructions for
City, state, and ZIP code completing this
form, see

‘Account number (optional)

Form 1099-G

Department of the Treasury -h

Instructions for
Forms 1099, 1098,
5498, and W-2G.

Internal Revenue Service




(C) CORRECTED (if checked)

City, state, and ZIP code

‘Account number (optional)

Form 1099-G

PAYER’S name, street address, city, state, and ZIP code 1 Unemployment compensation] OM No. 1545-0120
: 1990 Cera
> Suleorlocal = Government

fe or local income tax
refunds Payments
Statement for
$ Recipients of

PAYER'S Federal identification number | RECIPIENT'S identification number | 3 Refund is ortax year 4 Federal income tax withheld Copy B

$ For Recipient

RECIPIENT'S name 5 Discharge of indebtedness | 6 Taxable grants This 1s important tax

information and is

being furnished to the

$ $ internal Revenue
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Street address 7 Agnculture payments: 8 The amount in Box 2 applies required to file a
$ tomcome fromatrade or >] return, a negigence

. penalty or other

sanction may be
imposed on you if this
income is taxable and

the IRS determines

that it has not been
reported.

Department of the Treasury - Internal Revenue Service

(CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code 1 Unemployment compensation] OMB No. 1545-0120
$ 1990 Certain
2 State or local income tax Government
fund: Payments
refines Statement for y
$ Recipients of
PAYER’S Federal identification number | RECIPIENT'S identification number _ | 3 Refundis for tax year 4 Federal income tax withheld Copy B
$ For Recipient

RECIPIENT'S name

Street address

City, state, and ZIP code

5 Discharge of indebtedness

This 1s important tax

information and is
being furnished to the
$ Internal Revenue

6 Taxable grants

7 Agnculture payments

vice, If you are
8 The amount in Box? apples Service. Ifyou

to ncome from atrade or required to fle a
to mcome Ey] return, a negligence

penalty or other
sanction may be
Imposed on you if this
income is taxable and

the IRS determines

‘Account number (optional) RS determines
reported.
Form 1099-G Department of the Treasury - Internal Revenue Service
(1 CORRECTED (if checked)
PAYER'S name, street address, city, state, and ZIP code 1 Unemployment compensation] OMB No. 1545-0120
$ 1990 Certain
2 Salearlocall a Government
relunds nome Payments
Statement for
$ Recipients of
PAYER'S Federal identification number | RECIPIENT'S identification number 3 Refund is for tax year 4 Federal income tax withheld | Copy B
$ For Recipient

RECIPIENT'S name

Street address

City, state, and ZIP code

5 Discharge of indebtedness

This ts important tax
information and is
being furnished to the
$ internal Revenue
Service. If you are

6 Taxable grants

7 Agnculture payments

Yi

YY

‘Account number (optional)

Form 1099-G

3 The amount m Box Z applies
come from a trade or

>T

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.

Department of the Treasury - Internal Revenue Service