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. 1-2007)

a Wages, tips, and other compensation 

For Paperwork Reduction Act Notice, see page 2.

b

d

(Rev. January 2007)

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 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 Employer’s or payer’s

identification number (if known)

6

7 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

8 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

a Gross distribution

b Taxable amount

c Taxable amount not determined

Total distribution

e Capital gain (included in 8b)

f Federal income tax withheld 

g

h

i

j

State income tax withheld 

Local income tax withheld 

Employee contributions

Distribution codes

9 How did you determine the amounts on lines 7 and 8 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 ©

10

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, or (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.

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 or Form 1099-R

from your employer or payer before contacting the IRS or filing

Form 4852. After February 14, 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 15.

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)

d

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 the Social Security Administration (SSA) at the

telephone number shown on the statement. Alternatively, after

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 percent of the amount

of taxes that should have been paid,

● Civil fraud penalties equal to 75 percent 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 of

the Internal Revenue Code.
Form 4852 (Rev. 1-2007) 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 8—Form 1099-R. Complete line 8 by entering information

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

statement from your plan trustee to 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.

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

income tax withheld.

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

an IRA, SEP, or SIMPLE plan, write “IRA,” “SEP,” or “SIMPLE” in

the right margin.

Line 10. Explain what you did to get 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.

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 7b and 7e 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 7a.

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.

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

payment shown on line 8a is a total distribution.

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

your lump-sum distributions that you also included in 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.

c—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 8b 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—Form W-2. Complete line 7 by entering information

reported on Form W-2. If possible, use your final pay stub to

complete line 7. For additional information, get Form W-2 and

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