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. Page 2
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Form 4852 (Rev. 9-2017)
Page
Line 8—Form 1099-R. To the extent you received a Form 1099-R
• Accuracy-related penalties equal to 20 percent of the amount of
with correct information, complete line 8 by entering that correct
taxes that should have been paid,
information reported on your Form 1099-R. If you do not have
• Civil fraud penalties equal to 75 percent of the amount of taxes
complete and accurate information from a Form 1099-R, use a
that should have been paid, and
distribution statement from your plan trustee to help complete
• A $5,000 civil penalty for filing a frivolous return or submitting a
line 8. For additional information, get Form 1099-R and the
Instructions for Forms 1099-R and 5498.
specified frivolous submission as described by section 6702.
a—Gross distribution. Enter the total amount you received for
Specific Instructions
the year as a gross distribution.
b—Taxable amount. Enter the taxable amount of your
Lines 1 through 3. Enter your name, social security number, and
distribution.
current address including street, city, state, and ZIP code.
c—Taxable amount not determined. Check this box if you are
Line 4. Enter the year Form W-2 or Form 1099-R wasn't received or
unable to compute your taxable distribution. If you check this box,
was incorrect.
leave line 8b blank.
Line 5. Enter your employer’s or payer’s name, address, and ZIP
d—Total distribution. Check this box only if the payment shown
code.
on line 8a is a total distribution.
Line 6. Enter your employer’s or payer’s identification number, if
e—Capital gain (included in line 8b). Enter the capital gain on
known. If you had the same employer or payer in the prior year, use
your lump-sum distributions that you also included in line 8b. Only
the identification number shown on the prior year's Form W-2 or
certain individuals can elect to treat lump-sum distributions as a
Form 1099-R.
capital gain on Form 4972, Tax on Lump-Sum Distributions. See the
Line 7—Form W-2. To the extent you received a Form W-2 with
Instructions for Form 4972 for details.
correct information, complete line 7 by entering that correct
f—Federal income tax withheld. Enter the amount of federal
information reported on your Form W-2. If you do not have
income tax withheld.
complete and accurate information from a Form W-2, use your final
pay stub to help complete line 7. For additional information, get
g—State income tax withheld. Enter the amount of state income
Form W-2 and the General Instructions for Forms W-2 and W-3.
tax withheld.
a—Wages, tips, and other compensation. Enter your total
h—Local income tax withheld. Enter the amount of local income
wages received (include wages, noncash income, tips reported, and
tax withheld.
all other compensation before deductions for taxes, insurance, etc.).
i—Employee contributions. Enter your investment in the
b—Social security wages. Enter your total wages subject to
contract (after-tax contributions), if any, recovered tax free this year.
employee social security tax. Don't include social security tips and
j—Distribution codes. Enter the distribution code or codes that
allocated tips.
apply. If you are reporting more than one code, separate the codes
c—Medicare wages and tips. Enter your total wages and tips
with a comma. See the Instructions for Forms 1099-R and 5498 for
subject to Medicare tax. This amount may be required to be entered
a complete list of codes. If your distribution was from an IRA, SEP,
on Form 8959, Additional Medicare Tax. See Form 1040 instructions
or SIMPLE plan, write “IRA,” “SEP,” or “SIMPLE” in the right
to determine if you are required to complete Form 8959.
margin.
d—Social security tips. Enter the tips you reported to your
Line 9. Explain how you determined the amounts on line 7 or 8. For
employer for the year. The total of lines 7b and 7d cannot exceed
example, tell us if you estimated the amounts, used your pay stubs,
the social security wage base for the year reported in line 4. The
or used a statement reporting your distribution.
total amount of tips received during the year should be included in
Line 10. Explain what you did to get Form W-2, Form 1099-R, or
line 7a. You can find the social security wage base for any given
Form W-2c from your employer or payer.
year at The social security
wage base for a given year can be found in the Publication 15
Paperwork Reduction Act Notice. We ask for the information on
(Circular E), Employer's Tax Guide for that year, usually in the
Form 4852 to carry out the Internal Revenue laws of the United
“What's New” section at the beginning of the publication.
States. You are required to give us the information. We need it to
e—Federal income tax withheld. Enter the amount of federal
figure and collect the right amount of tax.
income taxes withheld from your wages for the year. Include the
You are not required to provide the information requested on a
20% excise tax withheld on excess parachute payments on this
form that is subject to the Paperwork Reduction Act unless the
line.
form displays a valid OMB control number. Books or records
f—State income tax withheld. Enter the amount of state income
relating to a form or its instructions must be retained as long as
tax withheld from wages for the year. Enter the name of the state.
their contents may become material in the administration of any
g—Local income tax withheld. Enter the amount of local income
Internal Revenue law. Generally, tax returns and return information
tax withheld from wages for the year. Enter the name of the locality.
are confidential, as required by section 6103.
h—Social security tax withheld. Enter the amount of social
The average time and expenses required to complete and file this
security tax withheld (not including the employer’s share), including
form vary depending on individual circumstances. For the
social security tax on tips.
estimated averages, see the instructions for your income tax return.
i—Medicare tax withheld. Enter the amount of Medicare tax
If you have suggestions for making Form 4852 simpler, we would
withheld (not including the employer’s share). This amount includes
be happy to hear from you. See the instructions for your income tax
the 1.45% Medicare tax withheld on all Medicare wages and tips
return.
you report on line 7c, as well as the 0.9% Additional Medicare Tax
withheld on any of those Medicare wages and tips above $200,000
for single taxpayers. For more information on the Medicare tax, see
the “What is the Additional Medicare Tax?” at
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