TO OPEN — TEAR OFF SIDE PERFORATIONS AND SLIDE FINGER UNDER TOP EDGE.

MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY

PO Box 1699 FIRST-CLASS MAIL
Jackson MS 39215-1699 U.S. POSTAGE & FEES PAID

MISSISSIPPI DEPARTMENT OF
OFFICIAL BUSINESS EMPLOYMENT SECURITY
PENALTY FOR PRIVATE USE, $300 JACKSON MS
PERMIT NO. 297
RETURN SERVICE REQUESTED

PAXTON BROOM
29 OODA LANE
COLUMBIA MS 39429

Instructions for Recipient Box 3. Identifies the tax year for which the box 2 refunds, credits, or
Account number. May show an account or other unique number the offsets shown were made. If there is no entry in this box, the refund is for
payer has assigned to distinguish your account. 2020 taxes.
Box 1. Shows the total unemployment compensation paid to you this Box 4. Shows backup withholding or withholding you requested on
year. Combine the box 1 amounts from all Forms 1099-G and report the unemployment compensation, Commodity Credit Corporation (CCC)
total as income on the unemployment compensation line of your tax loans, or certain crop disaster payments. Generally, a payer must backup
return. Except as explained below, this is your taxable amount. If you are withhold on certain payments if you did not give your taxpayer
married filing jointly, each spouse must figure his or her taxable amount identification number to the payer. See Form W-9 for information on
separately. If you expect to receive these benefits in the future, you can backup withholding. Include this amount on your income tax return as tax
ask the payer to withhold federal income tax from each payment. Or, you withheld.
can make estimated tax payments. For details, see Form 1040-ES. If you Box 5. Shows reemployment trade adjustment assistance (RTAA)
made contributions to a governmental unemployment compensation payments you received. Include on Form 1040 on the "Other income"
program or to a governmental paid family leave program and received a line. See the Form 1040 instructions.
payment from that program, the payer must issue a separate Form 1099- Box 6. Shows taxable grants you received from a federal, state, or local
G to report this amount to you. If you itemize deductions, you may deduct government.
your contributions on Schedule A (Form 1040) as taxes paid. If you do Box 7. Shows your taxable Department of Agriculture payments. If the
not itemize, you only need to include in income the amount that is in payer shown is anyone other than the Department of Agriculture, it
excess of your contributions. means the payer has received a payment, as a nominee, that is taxable
Box 2. Shows refunds, credits, or offsets of state or local income tax you to you. This may represent the entire agricultural subsidy payment
received. It may be taxable to you if you deducted the state or local received on your behalf by the nominee, or it may be your pro rata share
income tax paid on Schedule A (Form 1040). Even if you did not receive of the original payment. See Pub. 225 and the instructions for Schedule F
the amount shown, for example, because: (a) it was credited to your state (Form 1040) for information about where to report this income.
or local estimated tax, (b) it was offset against federal or state debts, (c) it Partnerships, see Form 8825 for how to report.
was offset against other offsets, or (d) you made a charitable contribution Box 8. If this box is checked, the amount in box 2 is attributable to an
from your refund, it is still taxable if it was deducted. If you received income tax that applies exclusively to income from a trade or business
interest on this amount, you should receive Form 1099-INT for the and is not a tax of general application. If taxable, report the amount in box
interest. However, the payer may include interest of less than $600 in the 2 on Schedule C or F (Form 1040), as appropriate.
blank box next to Box 9 on Form 1099-G. Regardless of whether the Box 9. Shows market gain on CCC loans whether repaid using cash or
interest is reported to you, report it as interest income on your tax return. CCC certificates. See the instructions for Schedule F (Form 1040).
See your tax return instructions. Boxes 10a–11. State income tax withheld reporting boxes.
Future developments. For the latest information about developments
related to Form 1099-G and its instructions, such as legislation enacted
after they were published ,go to www.irs.gov/form1099g.
MDES/2021-01-24/34420262/CLMT/1494922
 CORRECTED (if checked)
PAYER'S name, street address, city, state, ZIP code, and telephone no. 1 Unemployment compensation OMB No. 1545-0120

MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY Certain

$7,515.00
P O BOX 23088
JACKSON MS 39225-3088 2 State or local income tax
2020 Government
Payments
601-493-9427 refunds, credits, or offsets

Form 1099-G
PAYER'S federal identification number RECIPIENT'S identification number 3 Box 2 amount is for tax year 4 Federal income tax withheld
64-6000765 XXX-XX-2563 2020 $756.00 Copy B
For Recipient
RECIPIENT'S name 5 RTAA payments 6 Taxable grants

PAXTON BROOM This is important tax

$0.00 information and is being
Street address (including apt. no.)
furnished to the Internal
7 Agriculture payments 8 Check if box 2 is trade
Revenue Service. If you are
29 OODA LANE or business income
required to file a return, a
City, state, and ZIP code negligence penalty or other
9 Market gain
sanction may be imposed on
COLUMBIA, MS, 39429
you if this income is taxable
Account number (see instructions) 10a State 10b State Identification no. 10a State income tax withheld and the IRS determines that it
MS 64-6000765 $0.00 has not been reported.

Form 1099-G (keep for your records) www.irs.gov/form1099g Department of the Treasury - Internal Revenue Service

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

MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY Certain

$7,515.00
P O BOX 23088
JACKSON MS 39225-3088 2 State or local income tax
2020 Government
Payments
601-493-9427 refunds, credits, or offsets

Form 1099-G
PAYER'S federal identification number RECIPIENT'S identification number 3 Box 2 amount is for tax year 4 Federal income tax withheld Copy 2
64-6000765 XXX-XX-2563 2020 $756.00
To be filled with recipient's
RECIPIENT'S name 5 RTAA payments 6 Taxable grants
state income tax return, when
PAXTON BROOM required.
$0.00
Street address (including apt. no.) 7 Agriculture payments 8 Check if box 2 is trade
29 OODA LANE or business income

City, state, and ZIP code 9 Market gain

COLUMBIA, MS, 39429
Account number (see instructions) 10a State 10b State Identification no. 10a State income tax withheld
MS 64-6000765 $0.00

Form 1099-G www.irs.gov/form1099g Department of the Treasury - Internal Revenue Service