PAYER'S name, street address, city state, and ZIP code OMB No.
1545 - 0120
Statement for Recipients of
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF EMPLOYMENT SERVICES
OFFICE OF UNEMPLOYMENT COMPENSATION Certain
4058 MINNESOTA AVE., N.E. Government
WASHINGTON, D.C. 20019-3540 Phone: (202) 724-7000 Payments
FEDERAL I.D. NUMBER: 521181079 2020
Recipient's Identification No. 1. Unemployment 2. State or local 3. Box 2 is amount 4. Federal income tax
compensation income tax refunds, for tax year withheld
credits, or offsets
577114449 $24,978.00 $0.00
5. ATAA payments 6. Taxable grants
7. Agriculture 8. Check if box 2 is 10a. State
SIMPSON/JAMAL payments trade of business
2115 WINTERGREEN AVE
incomes DC
District Height MD 20747 11. State income tax 9. Market Gain
withheld
This information is being furnished to the Internal Revenue Service $0.00
DOES 1099 - G (Keep for your RECORDS) This is a substitute Form 1099 - G
Copy B For Recipient
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.
INSTRUCTIONS TO 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 next year, see Form 1040-ES for estimated tax
payments.
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 Form 1040 or 1040A.
Box 3. Identifies the tax year for which refund, credit or offset shown in box 2 was made. If there is no entry in this box, the refund is for taxes
for the above calendar year.
Box 4. Shows voluntary withholding on Unemployment Compensation, Commodity Credit Corporation loans, and certain crop disaster
payments. It also 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 5. Shows alternative trade adjustment assistance (ATAA) payments you received. Include on Form 1040 on the "Other Income" line.
See the Form 1040 instructions.
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
agriculture subsidy payment received on your behalf by the nominee, or it may be your prorate share of the original payment. See
Publication 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 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 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.
