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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Department of the Treasury - Internal Revenue Service

4852

Form

Substitute for Form W-2, Wage and Tax Statement, or Form 1099-R,

(Revised Oct. 1998)

OMB No.

Distributions From Pensions, Annuities, Retirement or

1545-0458

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

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

1. Name (First, middle, last)

2. Social security number (SSN)

3. Address

I have been unable to obtain (or have received an incorrect) Form W-2, Wage and

Please fill in the year at the end of the statement.

Tax Statement, or Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-sharing Plans IRA's, Insurance Contracts,

etc., from my employer or payer named below. I have notified the Internal Revenue Service of this fact. The amounts shown below are

my best estimates of all wages or payments paid to me and Federal taxes withheld by this employer or payer during

(year)

6. Employer's or payer's identification

5. Employer's or payer's name, address and ZIP code

number (if known)

7(A) Enter wages, compensations and taxes withheld

a. Wages

(Note: Include (1) the total wages paid

f. Federal income tax withheld

(2) noncash payments, (3) tips /reported and (4)

all other compensation before deductions for

g. State tax withheld

taxes, insurance, etc.)

(Name or state)

b. Social security wages

h. Local tax withheld

)

(Name of locality

c. Medicare wages

i. Social security tax withheld

d. Advance EIC payments

j. Medicare tax withheld

e. Social security tips

7(B). Enter distributions from pensions, annuities, retirement or profit-sharing plans, IRAs, insurance contracts, etc.

1. Gross Distribution

4. Federal Income Tax Withheld

2a. Taxable Amount

5. State Income Tax Withheld

2b. Taxable Amount not determined

6. Employee Contribution

Total Distribution

7. Net Unrealized Appreciation

3. Capital Gains

(included in 2a)

8. Enter Distribution Code

8. How did you determine the amounts in item 7 above?

9. Explain your efforts to obtain Form W-2, 1099-R, or W-2c, Statement of Corrected Income and Tax Amounts.

Importance Notice: If your employer has ceased operations or filed for bankruptcy, you may wish to send a copy of this form to the

Social Security Administration office listed in your telephone directory to ensure proper social security credit.

Paperwork Reduction Act Notice:

We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to give us the information. We

need it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of tax. You are not required to provide the

information requested on a form that is subject to the Paper Reduction Act unless the form displays a valid OMB control number. Books or records is

relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law.

Generally, tax returns and return information are confidential, as required by Code section 6103. The time needed to complete this form will vary

depending on individual circumstances. The estimated average time is 18 minutes. If you have comments concerning the occurrence of this time

estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Tax Forms Committee, Western Area

Distribution Center, Rancho Cordova, CA 95743 0001. DO NOT send this form to this office. Instead, attach it to your tax return.

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.

11. Date

10. Your signature

(mmddyyyy)

4852

Catalog No. 42058U

Form

(Rev. 10-98)