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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4852

Substitute for Form W-2, Wage and Tax Statement, or Form

1099-R, Distributions From Pensions, Annuities, Retirement or

Form

OMB No. 1545-0074

(Rev. December 2010)

Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Department of the Treasury

Attach to Form 1040, 1040A, 1040-EZ, or 1040X.

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)

Form W-2. Enter wages, tips, other compensation, and taxes withheld.

a Wages, tips, and other compensation

g State income tax withheld .

b Social security wages

(Name of state) .

c Medicare wages and tips

h Local income tax withheld .

d Advance EIC payment

(Name of locality)

e Social security tips

Social security tax withheld .

Federal income tax withheld

Medicare tax withheld

Form 1099-R. Enter distributions from pensions, annuities, retirement/profit-sharing plans, IRAs, insurance contracts, etc.

a Gross distribution .

Federal income tax withheld

b Taxable amount

g State income tax withheld .

c Taxable amount not determined .

h Local income tax withheld .

d Total distribution .

Employee contributions .

e Capital gain (included in line 8b) .

Distribution codes .

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.

Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true,

Sign

correct, and complete.

Here

Signature

Date

▶

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.

Purpose of form. Form 4852 serves as a substitute for Forms W-2,

Note. Retain a copy of Form 4852 for your records. Check your

W-2c, and 1099-R and is completed by taxpayers or their

Social Security Statement (received at least a full year after the

representatives when (a) their employer or payer does not give

date shown on line 4) against Form 4852. If the earnings you

them a Form W-2 or Form 1099-R or (b) an employer or payer has

reported on Form 4852 are not shown in the statement, you

issued an incorrect Form W-2 or Form 1099-R. Attach this form to

should contact the Social Security Administration (SSA) at the

the back of your income tax return, before any supporting forms or

telephone number shown on the statement. Alternatively, after

schedules.

September 30 following the date shown on line 4, you may contact

your local SSA office to verify wages reported by your employers.

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

Will I need to amend my return? If you receive a Form W-2, Form

filing Form 4852. If you do not receive the missing or corrected form

W-2c, or Form 1099-R after your return is filed with Form 4852, and

from your employer or payer by February 14, you may call the IRS

the information differs from the information reported on your return,

at 1-800-829-1040 for assistance. You must provide your name,

you must amend your return by filing Form 1040X, Amended U.S.

address (including ZIP code), phone number, social security

Individual Income Tax Return.

number, and dates of employment, and your employer's or payer's

Penalties. The IRS will challenge the claims of individuals who

name, address (including ZIP code), and phone number. The IRS

attempt to avoid or evade their federal tax liability by using Form

will contact the employer or payer for you and request the missing

4852 in a manner other than as prescribed. Potential penalties for

form. The IRS also will send you a Form 4852. If you do not receive

the improper use of Form 4852 include:

the missing form in sufficient time to file your income tax return

timely, you may use the Form 4852 that the IRS sent you.

4852

For Paperwork Reduction Act Notice, see page 2.

Form

(Rev. 12-2010)

Cat. No. 42058U

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