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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1
24852
Substitute for Form W-2, Wage and Tax Statement, or Form
1099-R, Distributions From Pensions, Annuities, Retirement or
Form
Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
(Rev. September 2014)
OMB No. 1545-0074
Attach to Form 1040, 1040A, 1040-EZ, or 1040X.
▶
Department of the Treasury
Information about Form 4852 is available at
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 .
.
.
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.
b Social security wages
.
.
.
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(Name of state) .
c Medicare wages and tips
.
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g Local income tax withheld .
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d Social security tips
.
.
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(Name of locality)
e Federal income tax withheld
h Social security tax withheld .
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i
Medicare tax withheld
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.
8
Form 1099-R. Enter distributions from pensions, annuities, retirement/profit-sharing plans, IRAs, insurance contracts, etc.
a Gross distribution .
f
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.
.
.
Federal income tax withheld
.
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b Taxable amount
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g State income tax withheld .
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c Taxable amount not determined .
h Local income tax withheld .
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d Total distribution .
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i
Employee contributions .
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e Capital gain (included in line 8b) .
j
Distribution codes .
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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. The IRS has created a page on IRS.gov for
Note. Retain a copy of Form 4852 for your records. To help protect
information about Form 4852, at Information
your social security benefits, keep a copy of Form 4852 until you
about any future developments affecting Form 4852 (such as
begin receiving social security benefits, just in case there is a
legislation enacted after we release it) will be posted on that page.
question about your work record and/or earnings in a particular
Purpose of form. Form 4852 serves as a substitute for Forms W-2,
year. After September 30 following the date shown on line 4, you
may use a my Social Security online account to verify wages
W-2c, and 1099-R and is completed by you or your representatives
reported by your employers. Please visit
when (a) your employer or payer does not issue you a Form W-2 or
Or, you may contact your local SSA office to verify wages reported
Form 1099-R or (b) an employer or payer has issued an incorrect
by your employer.
Form W-2 or Form 1099-R. Attach this form to the back of your
income tax return, before any supporting forms or schedules.
Will I need to amend my return? If you receive a Form W-2, Form
W-2c, or Form 1099-R after your return is filed with Form 4852, and
You should always attempt to get Form W-2, Form W-2c, or Form
1099-R from your employer or payer before contacting the IRS or
the information differs from the information reported on your return,
you must amend your return by filing Form 1040X, Amended U.S.
filing Form 4852. If you do not receive the missing or corrected form
Individual Income Tax Return.
from your employer or payer by February 14, you may call the IRS
at 1-800-829-1040 for assistance. You must provide your name,
Penalties. The IRS will challenge the claims of individuals who
address (including ZIP code), phone number, social security
attempt to avoid or evade their federal tax liability by using Form
number, and dates of employment, and your employer's or payer's
4852 in a manner other than as prescribed. Potential penalties for
name, address (including ZIP code), and phone number. The IRS
the improper use of Form 4852 include:
will contact your employer or payer and request the missing form.
• Accuracy-related penalties equal to 20 percent of the amount of
The IRS also will send you a Form 4852. If you do not receive the
taxes that should have been paid,
missing form in sufficient time to file your income tax return timely,
you may use the Form 4852 that the IRS sent you.
• Civil fraud penalties equal to 75 percent of the amount of taxes
that should have been paid, and
4852
For Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 9-2014)
Cat. No. 42058U
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