1. Gross Distribution

2a. Taxable Amount

2b. Taxable Amount not determined

 Total Distribution

3. Capital Gains (included in 2a)

4. Please fill in the year at the end of the statement. I have been unable to obtain (or have received an incorrect) Form W-2, Wage and

Tax Statement, or Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-sharing Plans IRA's, Insurance Contracts,

etc., from my employer or payer named below. I have notified the Internal Revenue Service of this fact. The amounts shown below are

my best estimates of all wages or payments paid to me and Federal taxes withheld by this employer or payer during .

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 1040,1040A, 1040-EZ or 1040X

1. Name (First, middle, last) 2. Social security number (SSN)

3. Address

(year)

6. Employer's or payer's identification

number (if known)

5. Employer's or payer's name, address and ZIP code

7(A) Enter wages, compensations and taxes withheld

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

8. How did you determine the amounts in item 7 above?

9. Explain your efforts to obtain Form W-2, 1099-R, or W-2c, Statement of Corrected Income and Tax Amounts.

Importance Notice: If your employer has ceased operations or filed for bankruptcy, you may wish to send a copy of this form to the

Social Security Administration office listed in your telephone directory to ensure proper social security credit.

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.

10. Your signature 11. Date (mmddyyyy)

Catalog No. 42058U Form 4852 (Rev. 10-98)

Form 4852

(Revised Oct. 1998) OMB No.

1545-0458

a. Wages (Note: Include (1) the total wages paid

 (2) noncash payments, (3) tips /reported and (4)

 all other compensation before deductions for

 taxes, insurance, etc.)

b. Social security wages

c. Medicare wages

d. Advance EIC payments

e. Social security tips

f. Federal income tax withheld

g. State tax withheld

 (Name or state)

h. Local tax withheld

 (Name of locality)

i. Social security tax withheld

j. Medicare tax withheld

4. Federal Income Tax Withheld

5. State Income Tax Withheld

6. Employee Contribution

7. Net Unrealized Appreciation

8. Enter Distribution Code

Paperwork Reduction Act Notice:

We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to give us the information. We

need it to ensure that you are complying with these laws and to allow us 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 Paper Reduction Act unless the form displays a valid OMB control number. Books or records is

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 Code section 6103. The time needed to complete this form will vary

depending on individual circumstances. The estimated average time is 18 minutes. If you have comments concerning the occurrence of this time

estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Tax Forms Committee, Western Area

Distribution Center, Rancho Cordova, CA 95743 0001. DO NOT send this form to this office. Instead, attach it to your tax return.
Line instructions:

1-3. Form W-2 and/or Form 1099-R statements.

4. Enter the year the taxpayer had taxable income from

 which Federal taxes were withheld and Form W-2 and/

 or Form 1099-R statements were not received.

5. Enter the employer's or payer's name, address, and zip

 code.

6. Enter the employer's identification number, if known.

7(A). Complete line 7(A) by entering Wages, Compensa-

 tions and Tax Withheld for the following items:

 a. Wages: Enter total wages received (include wages

 paid, noncash payments, tips reported, and all other

 compensation before deductions for taxes, insurance,

 etc.).

 b. Social security wages: Show the total wages paid

 subject to employee social security tax but not including

 social security tips and allocated tips.

 c. Medical wages: Enter the total wages and tips

 subject to Medicare tax.

 d. Advance EIC payment: Show the total amount

 received as advance earned income credit (EIC)

 payments.

 e. Social security tips: Show the amount the employee

 reported even if you did not have enough employee

 funds to collect the social security tax for the tips. The

 total of lines 7(A)b and 7(A)e should not be more than

 the maximum social security wage base for the current

 year. Report all tips on line 7(A)a along with wages and

 other compensation.

 f. Federal income tax withheld: Show the amount of

 federal income tax withheld from your wages for the year

 (this amount should not be reduced by any advance

 EIC payments made to you by your employer). Also,

 include the 20% excise tax withheld on excess parachute

 payments.

 g. State tax withheld: Show the amount of state income

 tax withheld from the taxpayer's wages for the year. Enter

 two-letter abbreviation of the name of the state.

 h. Local tax withheld: Show the amount of local

 income tax withheld, if any, from the taxpayer's wages

 for the year. Enter two-letter abbreviation of the name

 of the localities.

 i. Social security tax withheld: Show the total social

 security tax (not including the employer's share) withheld

 or paid by the employer for the employee, including social

 security tax on tips. (Do not reduce the amount

 by any advance EIC payments made to the employee).

 j. Medical tax withheld: Enter the total employee

 Medicare tax (not the employer's share) withheld or paid

 by the employer for the employee.

7(B). Complete line 7(B) by entering the information from

 Form 1099-R, Distributions From Pensions,

 Annuities, Retirement or Profit-Sharing Plans, IRA's

 and Tax Withheld for the following items:

 1. Gross Distribution: Show the total amount you

 received this year. For additional information, please see

 Pub 525, Taxable and Nontaxable Income.

 2a. Taxable amount: Show the amount of the

 distribution that is taxable. If you are not sure or do not

 know the amount of the distribution that is taxable, you

 should obtain one of the following publications from the

 IRS to help you figure the taxable amount:

General Instructions

Purpose of Form - Form 4852 is completed by taxpayers or their

representatives when their employer gives them an incorrect Form

W-2 or an incorrect Form 1099-R. This form is also used when the

employer or payer does not give the taxpayer a Form W-2 or

Form 1099-R. This form serves as a substitute for Form W-2,

W-2c, or 1099-R. Use this form to file your income tax return.

Form 4852 (Rev. 10-98)

- Publication 571, Tax-Shelter Annuity Programs

 for Employees of Public Schools and certain tax-

 exempt organization.

- Publication 575, Pension and Annuity Income

- Publication 590, Individual Retirement

 Arrangements (IRAs)

- Publication 721, Tax Guide to U.S. Civil Service

 Retirement Benefits,

 or

- Publication 939, General rule for Pensions and

 Annuities.

2b. Taxable amount not determined-Total

distribution Taxable amount not determined. Put an

"X" in this box if you are unable to reasonably obtain the

data needed to compute the taxable amount. If you mark

this box, leave line 2A blank. Total distribution Put an

"X" in this box only if the payment shown on line one is

a total distribution. A total distribution is one or more

distributions within one year in which the entire balance

of the account is distributed.

3. Capital Gains (included in 2a): If you received a

lump-sum distribution from a qualified plan and you were

born before 1936 (or you are the beneficiary of someone

born before 1936), you may be able to elect to treat this

amount as a capital gain on Form 4972. See the

instructions for Form 4972.

4. Federal income Tax Withheld: Show the amount

of federal Income taxes withheld.

5. State Income Tax Withheld: Show the amount of

state income taxes withheld.

6. Employee Contribution: Show the employee's

investment in the contract (after-tax contributions), if any,

recovered tax free this year.

7. Net Unrealized Appreciation: If you received a

lump-sum distribution from a qualified plan that includes

securities of the employer's company, the net unrealized

appreciation (NUA), which are any increases in value

of such securities while in the trust, is taxed only when

you sell the securities unless you choose to include it in

your gross income. See Publication 575 and the

instructions to Form 4972. If you do not receive a lumpsum distribution, the amount shown is the NUA

attributable to employee contributions, which is not taxed

until you sell the securities.

8. Distribution code: Please enter one of the codes

which describes the distribution you received:

 1. Early distribution, no known exception (in most

 cases under age 59 1/2);

 2. Early distribution exception applies;

 3. Disability;

 4. Death;

 5. Prohibited Transaction;

 6. Section 1035 exchange (a tax-free exchange of

 life insurance, annuity, or endowment contracts);

 7. Normal distribution;

 8. Excess contributions plus earnings/excess

 deferrals (and/or earnings) taxable in the following

 year, or;

 9. PS 58 costs (premiums paid by a trustee or

 custodian for current insurance protection, taxable

 to you currently).

 10. Other

Show how the amount on line 7(A) or line 7(B) was

determined.

Explain what you did to secure your Form W-2,

1099-R, or W-2c, Statement of Corrected Income and

Tax Amounts, from your employer?

8.

9.