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. Page 2
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Form 4852 (Rev. 9-2014)
Page
Line 8—Form 1099-R. Complete line 8 by entering information
• A $5,000 civil penalty for filing a frivolous return or submitting a
reported on Form 1099-R. If possible, use the distribution
specified frivolous submission as described by section 6702.
statement from your plan trustee to complete line 8. For additional
information, get Form 1099-R and the Instructions for Forms
Specific Instructions
1099-R and 5498.
Lines 1 through 3. Enter your name, social security number, and
a—Gross distribution. Enter the total amount you received for
current address including street, city, state, and ZIP code.
the year as a gross distribution.
Line 4. Enter the year Form W-2 or Form 1099-R was not received
b—Taxable amount. Enter the taxable amount of your
or was incorrect.
distribution.
Line 5. Enter your employer’s or payer’s name, address, and ZIP
c—Taxable amount not determined. Check this box if you are
code.
unable to compute your taxable distribution. If you check this box,
Line 6. Enter your employer’s or payer’s identification number, if
leave line 8b blank.
known. If you had the same employer or payer in the prior year, use
d—Total distribution. Check this box only if the payment shown
the identification number shown on the prior year's Form W-2 or
on line 8a is a total distribution.
Form 1099-R.
e—Capital gain (included in line 8b). Enter the capital gain on
Line 7—Form W-2. Complete line 7 by entering information
your lump-sum distributions that you also included in line 8b. Only
reported on Form W-2. If possible, use your final pay stub to
certain individuals can elect to treat lump-sum distributions as a
complete line 7. For additional information, get Form W-2 and the
capital gain on Form 4972, Tax on Lump-Sum Distributions. See the
General Instructions for Forms W-2 and W-3.
Instructions for Form 4972 for details.
a—Wages, tips, and other compensation. Enter your total
f—Federal income tax withheld. Enter the amount of federal
wages received (include wages, noncash income, tips reported, and
income tax withheld.
all other compensation before deductions for taxes, insurance, etc.).
g—State income tax withheld. Enter the amount of state income
b—Social security wages. Enter your total wages subject to
tax withheld.
employee social security tax. Do not include social security tips
h—Local income tax withheld. Enter the amount of local income
and allocated tips.
tax withheld.
c—Medicare wages and tips. Enter your total wages and tips
i—Employee contributions. Enter your investment in the
subject to Medicare tax. This amount may be required to be entered
contract (after-tax contributions), if any, recovered tax free this year.
on Form 8959. See Form 1040 instructions to determine if you are
required to complete Form 8959.
j—Distribution codes. Enter the distribution code or codes that
apply. If you are reporting more than one code, separate the codes
d—Social security tips. Enter the tips you reported to your
with a comma. See the Instructions for Forms 1099-R and 5498 for
employer for the year. The total of lines 7b and 7d cannot exceed
a complete list of codes. If your distribution was from an IRA, SEP,
the social security wage base for the year reported in line 4. The
or SIMPLE plan, write “IRA,” “SEP,” or “SIMPLE” in the right
total amount of tips received during the year should be included in
margin.
line 7a. You can find the social security wage base for any given
year at The
Line 9. Explain how you determined the amounts on line 7 or 8. For
social security wage base for a given year can be found in the
example, tell us if you estimated the amounts, used your pay stubs,
Publication 15 (Circular E), Employer's Tax Guide for that year,
or used a statement reporting your distribution.
usually in the “What's New” section at the beginning of the
Line 10. Explain what you did to get Form W-2, Form 1099-R, or
publication.
Form W-2c from your employer or payer.
e—Federal income tax withheld. Enter the amount of federal
income taxes withheld from your wages for the year. Include the
Paperwork Reduction Act Notice. We ask for the information on
20% excise tax withheld on excess parachute payments on this
Form 4852 to carry out the Internal Revenue laws of the United
line.
States. You are required to give us the information. We need it to
f—State income tax withheld. Enter the amount of state income
figure and collect the right amount of tax.
tax withheld from wages for the year. Enter the name of the state.
You are not required to provide the information requested on a
g—Local income tax withheld. Enter the amount of local income
form that is subject to the Paperwork Reduction Act unless the
tax withheld from wages for the year. Enter the name of the locality.
form displays a valid OMB control number. Books or records
relating to a form or its instructions must be retained as long as
h—Social security tax withheld. Enter the amount of social
their contents may become material in the administration of any
security tax withheld (not including the employer’s share), including
Internal Revenue law. Generally, tax returns and return information
social security tax on tips.
are confidential, as required by section 6103.
i—Medicare tax withheld. Enter the amount of Medicare tax
The average time and expenses required to complete and file this
withheld (not including the employer’s share). This amount includes
form vary depending on individual circumstances. For the
the 1.45% Medicare tax withheld on all Medicare wages and tips
estimated averages, see the instructions for your income tax 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.
If you have suggestions for making Form 4852 simpler, we would
be happy to hear from you. See the instructions for your income tax
return.
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