OMB No. 1545-0074

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.

Form 4852

 Attach to Form 1040, 1040A, 1040-EZ or 1040X. Department of the Treasury

Internal Revenue Service

Type or print your first name and middle initial. Social security number (SSN)

Cat. No. 42058U Form 4852 (Rev. 12-2005)

a Wages, tips, and other compensation

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

b

d

(Rev. December 2005)

1 2

3 Address

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.

4

I have notified the IRS of this fact. The amounts shown on line 7 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 Employer’s or payer’s identification

number (if known)

6

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

c

e

Social security wages

Medicare wages and tips

Advance EIC payment

Social security tips

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

f Federal income tax withheld

g State income tax withheld

h Local income tax withheld

i Social security tax withheld

j Medicare tax withheld

1 Gross distribution

2a Taxable amount

2b Taxable amount not determined

Total distribution

3 Capital gain (included in 2a)

4 Federal income tax withheld

5

6

7

8

State income tax withheld

Local income tax withheld

Employee contributions

Distribution codes

8 How did you determine the amounts in lines 7(A) and 7(B) above?

Explain your efforts to obtain Form W-2, Form 1099-R, or Form W-2c, Corrected Wage and Tax Statement.

Sign

Here

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

correct, and complete.

Signature  Date 

9

Purpose of form. Form 4852 serves as a substitute for

Forms W-2, W-2c and 1099-R and is completed by

taxpayers or their representatives when (a) their employer or

payer does not give them a Form W-2 or Form 1099-R and

(b) when an employer or payer has issued an incorrect Form

W-2 or Form 1099-R. Attach this form to your income tax

return.

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

your Social Security statement (received at least a full year

after the date shown on Line 4) against Form 4852. If the

earnings you reported on Form 4852 are not shown in the

statement, you should contact SSA at the telephone number

shown on the statement.

You should always attempt to get Form W-2 or

Form 1099-R from your employer or payer before contacting

the IRS or filing Form 4852. After February 14th, you may call

the IRS at 1-800-829-1040 if you still have not received

Form W-2 or Form 1099-R. Generally, do not file Form 4852

before April 15th. Employees affected by Hurricanes Katrina,

Rita, and Wilma should call the IRS at 1-866-562-5227 for

additional guidance.

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.

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

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

Form 4852, and the information differs from the information

reported on your return, you must amend your return by filing

Form 1040X, Amended U.S. Individual Income Tax Return.

Last name

(Name of state)

(Name of locality)
Form 4852 (Rev. 12-2005) Page 2

f—Federal income tax withheld. Enter the amount of

federal income taxes withheld from your wages for the year.

This amount should not be reduced by advance EIC

payments. Include the 20% excise tax withheld on excess

parachute payments on this line.

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

income tax withheld from wages for the year. Enter the name

of the state.

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

income tax withheld from wages for the year. Enter the name

of the locality.

i—Social security tax withheld. Enter the amount of

social security tax withheld (not including the employer’s

share), including social security tax on tips. This amount

should not be reduced by advance EIC payments.

j—Medicare tax withheld. Enter the amount of Medicare

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

amount should not be reduced by advance EIC payments.

Line 7(B)—Form 1099-R. Complete line 7(B) by entering

information reported on Form 1099-R. If possible, use the

distribution statement from your plan trustee to complete

Line 7(B). For additional information, get Form 1099-R and

the Instructions for Forms 1099-R and 5498.

1—Gross distribution. Enter the total amount you

received for the year as a gross distribution.

2a—Taxable amount. Enter the taxable amount of your

distribution.

2b—Checkboxes. Check only the box or boxes that apply

to your situation.

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

income tax withheld.

7—Employee contributions. Enter your investment in the

contract (after-tax contributions), if any, recovered tax free

this year.

8—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 an IRA, SEP, or SIMPLE plan, write

“IRA,” “SEP,” or “SIMPLE” in the right margin.

Line 9. Explain what you did to get Form W-2, Form 1099-R,

or Form W-2c from your employer or payer.

Privacy Act and 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. However, section

6103 allows or requires the Internal Revenue Service to

disclose or give the information shown on your return to

others as described in the Code. For example, we may

disclose your tax information to the Department of Justice for

civil and/or criminal litigation, and to cities, states, and the

District of Columbia for use in administering their tax laws.

We may also disclose this information to other countries

under a tax treaty, to federal and state agencies to enforce

federal nontax criminal laws, or to federal law enforcement

and intelligence agencies to combat terrorism.

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.

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. Do not include social

security tips and allocated tips.

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

tips subject to Medicare tax.

d—Advance EIC payment. Enter the total amount you

received as advance earned income credit (EIC) payments.

e—Social security tips. Enter the tips you reported to

your employer for the year. The total of lines b and e cannot

exceed the social security wage base for the year reported in

line 4. The total amount of tips received during the year

should be included in line a.

Line 8. Explain how you determined the amounts on line 7(A)

or 7(B). For example, tell us if you estimated the amounts,

used your pay stubs, or used a statement reporting your

distribution.

Total distribution. Mark an “X” in this box only if the

payment shown on line 1 is a total distribution.

3—Capital gain (included in 2a). Enter the capital gain on

your lump-sum distributions that you also included in line 2a.

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.

4—Federal income tax withheld. Enter the amount of

federal income tax withheld.

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

income tax withheld.

Taxable amount not determined. Mark an “X” in this box

if you are unable to compute your taxable distribution. If you

mark this box, leave line 2a blank.

Instructions

Line 4. Enter the year you received taxable income from

which federal income taxes were withheld and Form W-2 or

Form 1099-R was not received or was incorrect.

Lines 1–3. Enter your name, social security number (SSN)

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

code.

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

ZIP code.

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

number, if known. If you had the same employer or payer in

the prior year, use the identification number shown on that

Form W-2 or Form 1099-R.

Line 7(A)—Form W-2. Complete line 7(A) by entering

information reported on Form W-2. If possible, use your final

pay stub to complete Line 7(A). For additional information,

get Form W-2 and the Instructions for Forms W-2 and W-3.