Form 1099-G Certain Government Payments

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar
to the official IRS form. Do not file copy A downloaded from this website. The official
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about printing these tax forms.

8686

VOID

CORRECTED

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

1 Unemployment compensation

OMB No. 1545-0120

$

2011

2 State or local income tax
refunds, credits, or offsets

$
PAYER’S federal identification number

RECIPIENT’S identification number

Form

3 Box 2 amount is for tax year

Certain
Government
Payments

1099-G

4 Federal income tax withheld

$
RECIPIENT’S name

Street address (including apt. no.)

5 ATAA/RTAA payments

6 Taxable grants

$

$

7 Agriculture payments

8 Check if box 2 is
trade or business
income

$
City, state, and ZIP code

9 Market gain

Account number (see instructions)

10a State

For
Internal Revenue
Service Center

䊳

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

$
Form

1099-G

Cat. No. 14438M

Do Not Cut or Separate Forms on This Page

—

Copy A

File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the 2011
General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
PAYER’S name, street address, city, state, ZIP code, and telephone no.

1 Unemployment compensation

OMB No. 1545-0120

$

2011

2 State or local income tax
refunds, credits, or offsets

$
PAYER’S federal identification number

RECIPIENT’S identification number

3 Box 2 amount is for tax year

Form

1099-G

4 Federal income tax withheld

$
RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form

1099-G

5 ATAA/RTAA payments

Certain
Government
Payments

Copy B
For Recipient

6 Taxable grants

This is important tax
information and is
being furnished to the
$
$
Internal Revenue
Service. If you are
7 Agriculture payments
8 If checked, box 2 is
required
to file a return,
trade or business
䊳
$
a negligence penalty or
income
other sanction may be
9 Market gain
imposed on you if this
income is taxable and
$
the IRS determines that
10a State
10b State identification no. 11 State income tax withheld
it has not been
reported.
$

(keep for your records)

Department of the Treasury - Internal Revenue Service

Instructions for Recipient
Account number. May show an account or other unique number the payer
has assigned to distinguish your account.
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 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 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 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 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 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 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.

VOID

CORRECTED

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

1 Unemployment compensation

OMB No. 1545-0120

$

2011

2 State or local income tax
refunds, credits, or offsets

$
PAYER’S federal identification number

RECIPIENT’S identification number

Form

3 Box 2 amount is for tax year

Certain
Government
Payments

1099-G

4 Federal income tax withheld

Copy C

$
RECIPIENT’S name

Street address (including apt. no.)

5 ATAA/RTAA payments

6 Taxable grants

$

$

7 Agriculture payments

8 Check if box 2 is
trade or business
income

$
City, state, and ZIP code

9 Market gain

Account number (see instructions)

10a State

For Payer

䊳

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

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain Information
Returns.

$
Form

1099-G

Department of the Treasury - Internal Revenue Service

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).
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.
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.
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.