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. 12-2010)
Page
• Accuracy-related penalties equal to 20 percent of the amount of
Line 8—Form 1099-R. Complete line 8 by entering information
reported on Form 1099-R. If possible, use the distribution
taxes that should have been paid,
statement from your plan trustee to complete line 8. For additional
• Civil fraud penalties equal to 75 percent of the amount of taxes
information, get Form 1099-R and the Instructions for Forms
that should have been paid, and
1099-R and 5498.
a—Gross distribution. Enter the total amount you received for
• A $5,000 civil penalty for filing a frivolous return or submitting a
the year as a gross distribution.
specified frivolous submission as described by section 6702.
b—Taxable amount. Enter the taxable amount of your
distribution.
Specific Instructions
c—Taxable amount not determined. Check this box if you are
Lines 1 through 3. Enter your name, social security number, and
unable to compute your taxable distribution. If you check this box,
current address including street, city, state, and ZIP code.
leave line 8b blank.
Line 4. Enter the year you received taxable income from which
d—Total distribution. Check this box only if the payment shown
federal income taxes were withheld and Form W-2 or Form 1099-R
on line 8a is a total distribution.
was not received or was incorrect.
e—Capital gain (included in line 8b). Enter the capital gain on
Line 5. Enter your employer’s or payer’s name, address, and ZIP
your lump-sum distributions that you also included in line 8b. Only
code.
certain individuals can elect to treat lump-sum distributions as a
Line 6. Enter your employer’s or payer’s identification number, if
capital gain on Form 4972, Tax on Lump-Sum Distributions. See the
known. If you had the same employer or payer in the prior year, use
Instructions for Form 4972 for details.
the identification number shown on that Form W-2 or Form 1099-R.
f—Federal income tax withheld. Enter the amount of federal
Line 7—Form W-2. Complete line 7 by entering information
income tax withheld.
reported on Form W-2. If possible, use your final pay stub to
g—State income tax withheld. Enter the amount of state income
complete line 7. For additional information, get Form W-2 and the
tax withheld.
Instructions for Forms W-2 and W-3.
h—Local income tax withheld. Enter the amount of local income
a—Wages, tips, and other compensation. Enter your total
tax withheld.
wages received (include wages, noncash income, tips reported, and
i—Employee contributions. Enter your investment in the
all other compensation before deductions for taxes, insurance, etc.).
contract (after-tax contributions), if any, recovered tax free this year.
b—Social security wages. Enter your total wages subject to
j—Distribution codes. Enter the distribution code or codes that
employee social security tax. Do not include social security tips
apply. If you are reporting more than one code, separate the codes
and allocated tips.
with a comma. See the Instructions for Forms 1099-R and 5498 for
c—Medicare wages and tips. Enter your total wages and tips
a complete list of codes. If your distribution was from an IRA, SEP,
subject to Medicare tax.
or SIMPLE plan, write “IRA,” “SEP,” or “SIMPLE” in the right
d—Advance EIC payment. Enter the total amount you received
margin.
as advance earned income credit (EIC) payments.
Line 9. Explain how you determined the amounts on line 7 or 8. For
example, tell us if you estimated the amounts, used your pay stubs,
If the year reported on line 4 is after 2010, leave line 7d
TIP
or used a statement reporting your distribution.
blank.
Line 10. Explain what you did to get Form W-2, Form 1099-R, or
Form W-2c from your employer or payer.
e—Social security tips. Enter the tips you reported to your
employer for the year. The total of lines 7b and 7e cannot exceed
the social security wage base for the year reported in line 4. The
Paperwork Reduction Act Notice. We ask for the information on
total amount of tips received during the year should be included in
Form 4852 to carry out the Internal Revenue laws of the United
line 7a.
States. You are required to give us the information. We need it to
figure and collect the right amount of tax.
f—Federal income tax withheld. Enter the amount of federal
income taxes withheld from your wages for the year. This amount
You are not required to provide the information requested on a
should not be reduced by advance EIC payments. Include the 20%
form that is subject to the Paperwork Reduction Act unless the
excise tax withheld on excess parachute payments on this line.
form displays a valid OMB control number. Books or records
relating to a form or its instructions must be retained as long as
g—State income tax withheld. Enter the amount of state income
their contents may become material in the administration of any
tax withheld from wages for the year. Enter the name of the state.
Internal Revenue law. Generally, tax returns and return information
h—Local income tax withheld. Enter the amount of local income
are confidential, as required by section 6103.
tax withheld from wages for the year. Enter the name of the locality.
The average time and expenses required to complete and file this
i—Social security tax withheld. Enter the amount of social
form vary depending on individual circumstances. For the
security tax withheld (not including the employer’s share), including
estimated averages, see the instructions for your income tax return.
social security tax on tips. This amount should not be reduced by
If you have suggestions for making Form 4852 simpler, we would
advance EIC payments.
be happy to hear from you. See the instructions for your income tax
j—Medicare tax withheld. Enter the amount of Medicare tax
return.
withheld (not including the employer’s share). This amount should
not be reduced by advance EIC payments.
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