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4852

Substitute for Form W-2, Wage and Tax Statement, or Form

Form

1099-R, Distributions From Pensions, Annuities, Retirement or

OMB No. 1545-0074

(Rev. December 2005)

Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Department of the Treasury

Attach to Form 1040, 1040A, 1040-EZ or 1040X.

Internal Revenue Service

Type or print your first name and middle initial.

Last name

Social security number (SSN)

Address

Enter year in space provided and check one box. For the tax year ending December 31,

I have been unable to obtain (or have received an incorrect)

Form W-2 OR

Form 1099-R.

I have notified the IRS of this fact. The amounts shown on line 7 are my best estimates for all wages or payments made to me

and tax withheld by my employer or payer named on line 5.

Employer’s or payer’s name, address and ZIP code

Employer’s or payer’s identification

number (if known)

7(A)

Form W-2. Enter wages, tips, other compensation, and taxes withheld.

a Wages, tips, and other compensation

g State income tax withheld

Social security wages

(Name of state)

Medicare wages and tips

h Local income tax withheld

Advance EIC payment

(Name of locality)

Social security tips

Social security tax withheld

Federal income tax withheld

Medicare tax withheld

7(B)

Form 1099-R. Enter distributions from pensions, annuities, retirement/profit-sharing plans, IRAs, insurance contracts, etc.

Gross distribution

4 Federal income tax withheld

2a Taxable amount

State income tax withheld

2b Taxable amount not determined

Local income tax withheld

Total distribution

Employee contributions

Capital gain (included in 2a)

Distribution codes

How did you determine the amounts in lines 7(A) and 7(B) above?

Explain your efforts to obtain Form W-2, Form 1099-R, or Form W-2c, Corrected Wage and Tax Statement.

Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true,

correct, and complete.

Sign

Here

Signature

Date

Purpose of form. Form 4852 serves as a substitute for

If you received an incorrect Form W-2 or Form 1099-R,

Forms W-2, W-2c and 1099-R and is completed by

you should always attempt to have your employer or payer

taxpayers or their representatives when (a) their employer or

issue a corrected form before filing Form 4852.

payer does not give them a Form W-2 or Form 1099-R and

Note. Retain a copy of Form 4852 for your records. Check

(b) when an employer or payer has issued an incorrect Form

your Social Security statement (received at least a full year

W-2 or Form 1099-R. Attach this form to your income tax

after the date shown on Line 4) against Form 4852. If the

return.

earnings you reported on Form 4852 are not shown in the

You should always attempt to get Form W-2 or

statement, you should contact SSA at the telephone number

Form 1099-R from your employer or payer before contacting

shown on the statement.

the IRS or filing Form 4852. After February 14th, you may call

Will I need to amend my return? If you receive a Form W-2,

the IRS at 1-800-829-1040 if you still have not received

Form W-2c, or Form 1099-R, after your return is filed with

Form W-2 or Form 1099-R. Generally, do not file Form 4852

Form 4852, and the information differs from the information

before April 15th. Employees affected by Hurricanes Katrina,

reported on your return, you must amend your return by filing

Rita, and Wilma should call the IRS at 1-866-562-5227 for

Form 1040X, Amended U.S. Individual Income Tax Return.

additional guidance.

4852

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Cat. No. 42058U

Form

(Rev. 12-2005)

Form 4852 - Income Tax Return - Internal Revenue Service - Department Of The Treasury

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