Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-Sharing Plans, Ira'S Insurance Contracts, Etc.
Download a blank fillable Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-Sharing Plans, Ira'S Insurance Contracts, Etc. in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-Sharing Plans, Ira'S Insurance Contracts, Etc. with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
24852
Substitute for Form W-2, Wage and Tax Statement, or
Form 1099-R, Distributions From Pensions, Annuities, Retirement
Form
or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
(Rev. September 2017)
OMB No. 1545-0074
Attach to Form 1040, 1040A, 1040-EZ, or 1040X.
▶
Department of the Treasury
Go to for the latest information.
Internal Revenue Service
▶
1 Name(s) shown on return
2 Your social security number
3 Address
4 Enter year in space provided and check one box. For the tax year ending December 31,
,
Form W-2 OR
I have been unable to obtain (or have received an incorrect)
Form 1099-R.
I have notified the IRS of this fact. The amounts shown on line 7 or line 8 are my best estimates for all wages or payments
made to me and tax withheld by my employer or payer named on line 5.
5 Employer’s or payer’s name, address, and ZIP code
6 Employer’s or payer’s
identification number (if known)
7
Form W-2. Enter wages, tips, other compensation, and taxes withheld.
a Wages, tips, and other compensation
f
State income tax withheld .
.
.
.
.
b Social security wages
.
.
.
.
(Name of state) .
c Medicare wages and tips
.
.
.
g Local income tax withheld .
.
.
.
.
d Social security tips
.
.
.
.
.
(Name of locality)
e Federal income tax withheld
h Social security tax withheld .
.
.
.
.
.
.
i
Medicare tax withheld
.
.
.
.
.
.
8
Form 1099-R. Enter distributions from pensions, annuities, retirement or profit-sharing plans, IRAs, insurance contracts, etc.
a Gross distribution .
f
.
.
.
.
.
Federal income tax withheld
.
.
.
.
b Taxable amount
g State income tax withheld .
.
.
.
.
.
.
.
.
.
.
c Taxable amount not determined .
h Local income tax withheld .
.
.
.
.
d Total distribution .
.
.
.
.
.
i
Employee contributions .
.
.
.
.
.
e Capital gain (included in line 8b) .
j
Distribution codes .
.
.
.
.
.
.
.
9 How did you determine the amounts on lines 7 and 8 above?
10 Explain your efforts to obtain Form W-2, Form 1099-R, or Form W-2c, Corrected Wage and Tax Statement.
General Instructions
If you received an incorrect Form W-2 or Form 1099-R, you
should always attempt to have your employer or payer issue a
Section references are to the Internal Revenue Code.
corrected form before filing Form 4852.
Future developments. Information about any future developments
Note: Retain a copy of Form 4852 for your records. To help protect
affecting Form 4852 (such as legislation enacted after we release it)
your social security benefits, keep a copy of Form 4852 until you
will be available at .
begin receiving social security benefits, just in case there is a
Purpose of form. Form 4852 serves as a substitute for Forms W-2,
question about your work record and/or earnings in a particular
year. After September 30 following the date shown on line 4, you
W-2c, and 1099-R and is completed by you or your representatives
may use your Social Security online account to verify wages
when (a) your employer or payer doesn't issue you a Form W-2 or
reported by your employers. Please visit
Form 1099-R or (b) an employer or payer has issued an incorrect
Or, you may contact your local SSA office to verify wages reported
Form W-2 or Form 1099-R. Attach this form to the back of your
by your employer.
income tax return, before any supporting forms or schedules.
Will I need to amend my return? If you receive a Form W-2, Form
You should always attempt to get your Form W-2, Form W-2c, or
W-2c, or Form 1099-R after your return is filed with Form 4852, and
Form 1099-R from your employer or payer before contacting the
the information you receive differs from the information reported on
IRS or filing Form 4852. If you do not receive the missing or
your return, you must amend your return by filing Form 1040X,
corrected form from your employer or payer by the end of February,
Amended U.S. Individual Income Tax Return. You are responsible
you may call the IRS at 1-800-829-1040 for assistance. You must
provide your name, address (including ZIP code), phone number,
for filing your income tax return with accurate information regardless
of whether you receive a Form W-2, Form W-2c, or Form 1099-R
social security number, and dates of employment. You must also
and regardless of whether the information on any forms received is
provide your employer's or payer's name, address (including ZIP
correct.
code), and phone number. The IRS will contact your employer or
payer and request the missing form. The IRS will also send you a
Penalties. The IRS will challenge the claims of individuals who
Form 4852. If you don't receive the missing form in sufficient time to
attempt to avoid or evade their federal tax liability by using Form
file your income tax return timely, you may use the Form 4852 that
4852 in a manner other than as prescribed. Potential penalties for
the IRS sent you.
the improper use of Form 4852 include:
4852
For Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 9-2017)
Cat. No. 42058U
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Ira's Insurance Contracts, Etc. - Internal Revenue Service
Financial
Form Ct-4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Ira's, Insuarance Contracts, Etc - Connecticut - 1995
Financial
Form Ct-4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Form Ct-4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Form Ct-4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Form Ct-4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc
Financial
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.
Financial
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.
Financial
Related Categories
Parent category: Financial