Form Sc4852 - Substitute For Form W-2 Wage And Tax Statement
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11350
STATE OF SOUTH CAROLINA
SC4852
DEPARTMENT OF REVENUE
SUBSTITUTE FOR FORM W-2
(Rev. 4/9/14)
3236
WAGE AND TAX STATEMENT
File This Form With Your South Carolina Tax Return
(Complete a Separate Form For Each Employer)
Your full name (Type or print)
Social Security Number
Address
State
Zip Code
Has your present address been furnished
Your telephone number
Period worked for this employer
to the employer?
Yes
No
Employer's name
Employer's address, city, state and zip code
Employer's Identification number (if known)
Employer's telephone number
Type of business
Amount of wages
Estimated South Carolina income taxes withheld
Tax year
Wages Paid in:
cash
check
Check applicable box:
Please mark the form you are referencing:
1.
Employer has not furnished me with form(s).
1. W-2 form
3. W-2C form
2.
Form(s) given to me by employer is/are incorrect.
3.
Form(s) is/are lost.
2. W-2P form
4. 1099 form
4.
Form(s) given to me by employer is/are illegible.
Attach copies of pay stubs, military leave and earnings statement, or other documentation to support your claim.
REQUIRED INFORMATION
Explain how you calculated the amount of wages received and the amount of estimated South Carolina income taxes withheld.
Explain the efforts made to obtain an accurate form W-2, W-2P, W-2C, 1099:
I declare that this return and all attachments are true, correct and complete to the best of my knowledge and belief. To wilfully furnish a false or
fraudulent statement to the Department is a crime.
Signature
Date
Social Security Privacy Act
It is mandatory that you provide your social security number on this tax form. 42 U.S.C 405(c)(2)(C)(i) permits a state to use an individual's social
security number as means of identification in administration of any tax. SC Regulation 117-201 mandates that any person required to make a return to
the SC Department of Revenue shall provide identifying numbers, as prescribed, for securing proper identification. Your social security number is used
for identification purposes.
32361024
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