Instructions For Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-R, Distributions From Pensions, Annuities, Retirement Or Profit-Sharing Plans, Iras, Insurance Contracts, Etc.

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Form 4852 (Rev. 12-2005)
Page
Taxable amount not determined. Mark an “X” in this box
Instructions
if you are unable to compute your taxable distribution. If you
Lines 1–3. Enter your name, social security number (SSN)
mark this box, leave line 2a blank.
and current address including street, city, state, and ZIP
Total distribution. Mark an “X” in this box only if the
code.
payment shown on line 1 is a total distribution.
Line 4. Enter the year you received taxable income from
3—Capital gain (included in 2a). Enter the capital gain on
which federal income taxes were withheld and Form W-2 or
your lump-sum distributions that you also included in line 2a.
Form 1099-R was not received or was incorrect.
Only certain individuals can elect to treat lump-sum
Line 5. Enter your employer’s or payer’s name, address, and
distributions as a capital gain on Form 4972, Tax on
ZIP code.
Lump-Sum Distributions. See the Instructions for Form 4972
Line 6. Enter your employer’s or payer’s identification
for details.
number, if known. If you had the same employer or payer in
4—Federal income tax withheld. Enter the amount of
the prior year, use the identification number shown on that
federal income tax withheld.
Form W-2 or Form 1099-R.
5—State income tax withheld. Enter the amount of state
Line 7(A)—Form W-2. Complete line 7(A) by entering
income tax withheld.
information reported on Form W-2. If possible, use your final
6—Local income tax withheld. Enter the amount of local
pay stub to complete Line 7(A). For additional information,
income tax withheld.
get Form W-2 and the Instructions for Forms W-2 and W-3.
7—Employee contributions. Enter your investment in the
a—Wages, tips, and other compensation. Enter your
contract (after-tax contributions), if any, recovered tax free
total wages received (include wages, noncash income, tips
this year.
reported, and all other compensation before deductions for
8—Distribution codes. Enter the distribution code or
taxes, insurance, etc.).
codes that apply. If you are reporting more than one code,
b—Social security wages. Enter your total wages subject
separate the codes with a comma. See the Instructions for
to employee social security tax. Do not include social
Forms 1099-R and 5498 for a complete list of codes. If your
security tips and allocated tips.
distribution was from an IRA, SEP, or SIMPLE plan, write
c—Medicare wages and tips. Enter your total wages and
“IRA,” “SEP,” or “SIMPLE” in the right margin.
tips subject to Medicare tax.
Line 8. Explain how you determined the amounts on line 7(A)
d—Advance EIC payment. Enter the total amount you
or 7(B). For example, tell us if you estimated the amounts,
received as advance earned income credit (EIC) payments.
used your pay stubs, or used a statement reporting your
e—Social security tips. Enter the tips you reported to
distribution.
your employer for the year. The total of lines b and e cannot
Line 9. Explain what you did to get Form W-2, Form 1099-R,
exceed the social security wage base for the year reported in
or Form W-2c from your employer or payer.
line 4. The total amount of tips received during the year
should be included in line a.
Privacy Act and Paperwork Reduction Act Notice. We ask
f—Federal income tax withheld. Enter the amount of
for the information on Form 4852 to carry out the Internal
federal income taxes withheld from your wages for the year.
Revenue laws of the United States. You are required to give
This amount should not be reduced by advance EIC
us the information. We need it to figure and collect the right
payments. Include the 20% excise tax withheld on excess
amount of tax.
parachute payments on this line.
You are not required to provide the information requested
g—State income tax withheld. Enter the amount of state
on a form that is subject to the Paperwork Reduction Act
income tax withheld from wages for the year. Enter the name
unless the form displays a valid OMB control number. Books
of the state.
or records relating to a form or its instructions must be
h—Local income tax withheld. Enter the amount of local
retained as long as their contents may become material in
income tax withheld from wages for the year. Enter the name
the administration of any Internal Revenue law.
of the locality.
Generally, tax returns and return information are
i—Social security tax withheld. Enter the amount of
confidential, as required by section 6103. However, section
social security tax withheld (not including the employer’s
6103 allows or requires the Internal Revenue Service to
share), including social security tax on tips. This amount
disclose or give the information shown on your return to
should not be reduced by advance EIC payments.
others as described in the Code. For example, we may
j—Medicare tax withheld. Enter the amount of Medicare
disclose your tax information to the Department of Justice for
tax withheld (not including the employer’s share). This
civil and/or criminal litigation, and to cities, states, and the
amount should not be reduced by advance EIC payments.
District of Columbia for use in administering their tax laws.
We may also disclose this information to other countries
Line 7(B)—Form 1099-R. Complete line 7(B) by entering
information reported on Form 1099-R. If possible, use the
under a tax treaty, to federal and state agencies to enforce
federal nontax criminal laws, or to federal law enforcement
distribution statement from your plan trustee to complete
and intelligence agencies to combat terrorism.
Line 7(B). For additional information, get Form 1099-R and
the Instructions for Forms 1099-R and 5498.
The average time and expenses required to complete and
file this form vary depending on individual circumstances. For
1—Gross distribution. Enter the total amount you
the estimated averages, see the instructions for your income
received for the year as a gross distribution.
tax return.
2a—Taxable amount. Enter the taxable amount of your
If you have suggestions for making Form 4852 simpler, we
distribution.
would be happy to hear from you. See the instructions for your
2b—Checkboxes. Check only the box or boxes that apply
income tax return.
to your situation.

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