Form Il-4852 - Substitute For Unobtainable Form W-2
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Illinois Department of Revenue
IL-4852
Substitute for Unobtainable Form W-2
Attach this form to your Form IL-1040
IL Attachment No. 5
Step 1: Read this information first
What must I attach to Form IL-4852?
You must attach proof of wages and withholding, such as copies of
Who should file Form IL-4852?
check stubs or a letter from your employer, on company letterhead.
You should file Form IL-4852, Substitute for Unobtainable Form W-2,
Your check stubs or letter should include the following information:
if you did not receive or were not able to obtain a Form W-2, Wage
•
your name,
and Tax Statement, from your employer showing that Illinois Income
•
your Social Security number,
Tax was withheld from your wages. However, you should not use this
•
tax year,
form to correct the information on your Form W-2. You must contact
•
amount of Illinois Income Tax withheld, and
your employer for a corrected Form W-2.
•
total wages.
You should only file Form IL-4852 after you have given your
We will accept a copy of your properly completed U.S. Form 4852,
employer sufficient time to mail your Form W-2 and after you have
along with any required attachments, as proof of your Illinois Income
exhausted all efforts to obtain one.
Tax withheld from your wages.
You must complete a separate Form IL-4852, filling in the information
in all steps, for each Form W-2 not received.
Step 2: Provide the following information
1
3
Name
Address
Street address
–
–
2
SSN
Social Security number
City
State
ZIP
Step 3: Identify your employer
–
4
6
Name of employer
FEIN (if known)
Federal employer identification number
5
7
Address
Owner or contact person
Street address
(
)
8
Phone number
City
State
ZIP
Step 4: Complete the following
9
9
Enter the tax year for which you are filing this form.
10
10
Enter the total amount of gross wages that your employer paid you.
______________ 00
11
Enter the total amount of Illinois Income Tax that your employer withheld from your wages.
11
Include this amount on the Illinois Income Tax withheld line of your Form IL-1040.
______________ 00
12
How did you determine the total amount of gross wages and the total amount of Illinois Income Tax withheld?
13
State the reason your employer did not give you your Form W-2.
14
Explain your efforts to obtain your Form W-2.
Step 5: Sign below
Under penalties of perjury, I state that I have examined this form and any attachments and, to the best of my knowledge, they are true, correct, and
complete.
(
)
Your signature
Date
Daytime phone number
*462401110*
This form is authorized as outlined under the Illinois Income Tax Act. Disclosure of
this information is required. Failure to provide information could result in a penalty.
IL-4852 (R-12/14)
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