Form M-4852 - Substitute For Form W-2, Wage And Tax Statement
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1Form M-4852
Massachusetts
Substitute for Form W-2,
Department of
Wage and Tax Statement
Revenue
Complete a separate form for each employer or payer for which a wage or earnings statement is not available.
Your information
1 Last name
First name
Middle initial
2 Social Security no.
3 Street address
City/Town
State
Zip
Form W-2 not received
I have been unable to obtain (or have received an incorrect) Form W-2, Wage and Tax Statement, from the employer or payer named below. The amounts shown are
my best estimates of all wages or payments paid to me and the Massachusetts taxes withheld by this employer or payer.
4 Year
5 Employer or payer’s name
Identification number
Telephone number
Employer or payer’s address
City/Town
State
Zip
Include in line 6 the total of wages paid, non-cash payments, tips reported and all other compensation before deductions for taxes, insurance, etc.
6 Wages
7 Massachusetts withholding*
8 Social Security and Medicare tax
*To calculate estimated Massachusetts withholding tax, multiply gross income from your federal Form W-2 by 5%. Call 800-829-1040 for copy of your federal Form W-2. Please
note that, for a fee, the Social Security Administration may be able to provide you with your state W-2; call them at 800-772-1213 for more information.
9 Explain how you determined the amounts in lines 6 through 8:
10 Describe your efforts to obtain Forms W-2, 1099R or W-2C, Statement of Corrected Income and Tax Amounts, from your employer or payer:
10a At any time were you a full-time student?
Yes
No
10b At any time did you request that your employer or payer not withhold Massachusetts income tax because you reasonably expected to earn less than $8,000?
Yes
No
Signature
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.
Signature
Date
For DOR use Wages
Withholding
FICA
Approved
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