Form 4852

(Rev. September 2020)

Department of the Treasury 

Internal Revenue Service 

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.

▶ Attach to Form 1040, 1040-SR, or 1040-X.

▶ Go to www.irs.gov/Form4852 for the latest information.

OMB No. 1545-0074

Attachment 

Sequence No. 04 

You must take the following steps before filing Form 4852

• Attempt to get your Form W-2, Form W-2c, or Form 1099-R (original or corrected) from your employer or payer before contacting the IRS or 

filing Form 4852.

• If you don’t receive the missing or corrected form from your employer or payer by the end of February, you may call the IRS at 

800-829-1040 for assistance. You must provide your name, address (including ZIP code), phone number, social security number, and dates of 

employment. You must also provide your employer’s or payer’s name, address (including ZIP code), and phone number. The IRS will contact 

your employer or payer and request the missing form. The IRS will also send you a Form 4852. If you don’t receive the missing form in 

sufficient time to file your income tax return timely, you may use the Form 4852 that the IRS sent you to file with your return.

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, , 

I have been unable to obtain (or have received an incorrect) Form W-2 OR 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 

 TIN (if known) 

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

a Wages, tips, and other compensation 

b Social security wages . . . .

c Medicare wages and tips . . .

d Social security tips . . . . .

e Federal income tax withheld . .

f State income tax withheld . . . . .

(Name of state) .

g Local income tax withheld . . . . .

(Name of locality) 

h Social security tax withheld . . . . .

i Medicare tax withheld . . . . . .

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

a Gross distribution . . . . . .

b Taxable amount . . . . . .

c Taxable amount not determined .

d Total distribution . . . . . .

e Capital gain (included on line 8b) .

f Federal income tax withheld . . . .

g State income tax withheld . . . . .

(Name of state) .

h Local income tax withheld . . . . .

(Name of locality) 

i Employee contributions . . . . . .

j 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 (original or corrected), or Form W-2c, Corrected Wage and Tax Statement. 

General Instructions 

Section references are to the Internal Revenue Code.

Future developments. For the latest information about developments 

related to Form 4852, such as legislation enacted after it was published, 

go to www.irs.gov/Form4852.

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

W-2c, and 1099-R (original or corrected) and is completed by you or 

your representatives when (a) your employer or payer doesn’t issue you 

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

incorrect Form W-2 or Form 1099-R. Attach this form to the back of 

your income tax return before any supporting forms or schedules. 

You should always attempt to get your Form W-2, Form W-2c, or 

Form 1099-R (original or corrected) from your employer or payer before 

contacting the IRS or filing Form 4852. If you don’t receive the missing 

or corrected form from your employer or payer by the end of February, 

you may call the IRS at 800-829-1040 for assistance. You must provide 

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

number, and dates of employment. You must also provide your 

employer’s or payer’s name, address (including ZIP code), and phone 

number. The IRS will contact your employer or payer and request the 

missing form. The IRS will also send you a Form 4852. If you don’t 

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

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

For Paperwork Reduction Act Notice, see page 2. Cat. No. 42058U Form 4852 (Rev. 9-2020) 
Form 4852 (Rev. 9-2020) Page 2 

If you received an incorrect Form W-2 or Form 1099-R, you should 

always attempt to have your employer or payer issue a corrected form 

before filing Form 4852. 

Note: Retain a copy of Form 4852 for your records. To help protect 

your social security benefits, keep a copy of Form 4852 until you 

begin receiving social security benefits, just in case there is a question 

about your work record and/or earnings in a particular year. After 

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

Social Security online account to verify wages reported by your 

employers. Please visit www.SSA.gov/myaccount. Or, you may contact 

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

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

W-2c, or Form 1099-R (original or corrected) after your return is filed 

with Form 4852, and the information you receive indicates that the 

information reported on your original return is incorrect, you must 

amend your return by filing Form 1040-X, Amended U.S. Individual 

Income Tax Return. You are responsible for filing your income tax return 

with accurate information regardless of whether you receive a Form 

W-2, Form W-2c, or Form 1099-R (original or corrected) and regardless 

of whether the information on any forms received is correct.

Penalties. The IRS will challenge the claims of individuals who attempt 

to avoid or evade their federal tax liability by using Form 4852 in a 

manner other than as prescribed. Potential penalties for the improper 

use of Form 4852 include: 

• Accuracy-related penalties equal to 20% of the amount of taxes that 

should have been paid, 

• Civil fraud penalties equal to 75% of the amount of taxes that should 

have been paid, and 

• A $5,000 civil penalty for filing a frivolous return or submitting a 

specified frivolous submission as described by section 6702.

Specific Instructions 

Lines 1 through 3. Enter your name, social security number, and 

current address including street, city, state, and ZIP code. 

Line 4. Enter the year for which Form W-2 or Form 1099-R wasn’t 

received or was incorrect. 

Line 5. Enter your employer’s or payer’s name, address, and ZIP code. 

Line 6. Enter your employer’s or payer’s taxpayer identification number 

(TIN), if known. If you had the same employer or payer in the prior year, 

use the employer identification number (EIN) shown on the prior year’s 

Form W-2 or Form 1099-R. If you don’t know the EIN, but you know a 

different TIN associated with the employer or payer, such as a social 

security number (SSN), you may enter that TIN. 

Line 7—Form W-2. To the extent the Form W-2 you received reported 

correct information, complete line 7 by entering that correct information. 

If you don’t have complete and accurate information from a Form W-2, 

use your final pay stub to help complete line 7. For additional 

information, get Form W-2 and the General Instructions for Forms W-2 

and W-3. 

a—Wages, tips, and other compensation. Enter your total wages 

received (include wages, noncash income, tips reported, and all other 

compensation before deductions for taxes, insurance, etc.). 

b—Social security wages. Enter your total wages subject to 

employee social security tax. Don’t include social security tips and 

allocated tips. 

c—Medicare wages and tips. Enter your total wages and tips 

subject to Medicare tax. This amount may be required to be entered on 

Form 8959, Additional Medicare Tax. See the Instructions for Forms 

1040 and 1040-SR to determine if you are required to complete Form 

8959. 

d—Social security tips. Enter the tips you reported to your employer 

for the year. The total of lines 7b and 7d can’t exceed the social security 

wage base for the year reported on line 4. The total amount of tips 

received during the year should be included on line 7a. You can find the 

social security wage base for any given year at www.SSA.gov/OACT/

COLA/cbb.html. The social security wage base for a given year can be 

found in Pub. 15 (Circular E), Employer’s Tax Guide, for that year, 

usually under What’s New at the beginning of the publication.

e—Federal income tax withheld. Enter the amount of federal 

income taxes withheld from your wages for the year. Include the 20% 

excise tax withheld on excess parachute payments on this line. 

f—State income tax withheld. Enter the amount of state income tax 

withheld from wages for the year. Enter the name of the state. 

g—Local income tax withheld. Enter the amount of local income tax 

withheld from wages for the year. Enter the name of the locality. 

h—Social security tax withheld. Enter the amount of social security 

tax withheld (not including the employer’s share), including social 

security tax on tips. 

i—Medicare tax withheld. Enter the amount of Medicare tax 

withheld (not including the employer’s share). This amount includes the 

1.45% Medicare tax withheld on all Medicare wages and tips 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. For more 

information on Additional Medicare Tax, go to www.irs.gov/AdMT.

Line 8—Form 1099-R. To the extent the Form 1099-R you received 

reported correct information, complete line 8 by entering that correct 

information. If you don’t have complete and accurate information from a 

Form 1099-R, use a distribution statement from your plan trustee to help 

complete line 8. For additional information, get Form 1099-R and the 

Instructions for Forms 1099-R and 5498.

a—Gross distribution. Enter the total amount you received for the 

year as a gross distribution. 

b—Taxable amount. Enter the taxable amount of your distribution. 

c—Taxable amount not determined. Check this box if you are 

unable to compute your taxable distribution. If you check this box, leave 

line 8b blank. 

d—Total distribution. Check this box only if the payment shown on 

line 8a is a total distribution. 

e—Capital gain (included on line 8b). Enter the capital gain on your 

lump-sum distributions that you also included on line 8b. Only certain 

individuals can elect to treat lump-sum distributions as a capital gain on 

Form 4972, Tax on Lump-Sum Distributions. See the Instructions for 

Form 4972 for details. 

f—Federal income tax withheld. Enter the amount of federal income 

tax withheld. 

g—State income tax withheld. Enter the amount of state income tax 

withheld. Enter the name of the state.

h—Local income tax withheld. Enter the amount of local income tax 

withheld. Enter the name of the locality.

i—Employee contributions. Enter your investment in the contract 

(after-tax contributions), if any, recovered tax free this year. 

j—Distribution codes. Enter the distribution code or codes that 

apply. If you are reporting more than one code, separate the codes with 

a comma. See the Instructions for Forms 1099-R and 5498 for a 

complete list of codes. If your distribution was from a traditional IRA, 

SEP IRA, or SIMPLE IRA, write “IRA,” “SEP,” or “SIMPLE” in the right 

margin. 

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, or 

used a statement reporting your distribution. 

Line 10. Explain any attempts made to get the missing or corrected 

Form W-2, Form 1099-R, or Form W-2c from your employer or payer. 

Paperwork Reduction Act Notice. We ask for the information on Form 

4852 to carry out the Internal Revenue laws of the United States. You 

are required to give us the information. We need it to figure and collect 

the right amount of tax. 

You are not required to provide the information requested on a form 

that is subject to the Paperwork Reduction Act unless the form displays 

a valid OMB control number. Books or records relating to a form or its 

instructions must be retained as long as their contents may become 

material in the administration of any Internal Revenue law. Generally, tax 

returns and return information are confidential, as required by section 

6103. 

The average time and expenses required to complete and file this 

form vary depending on individual circumstances. For the estimated 

averages, see the instructions for your income tax return. 

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.