Form 4852

(Rev. December 2010)

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.

OMB No. 1545-0074

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 

 identification number (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 Advance EIC payment . . . .

e Social security tips . . . . .

f Federal income tax withheld . .

g State income tax withheld . . . . .

(Name of state) .

h Local income tax withheld . . . . .

(Name of locality) 

i Social security tax withheld . . . . .

j Medicare tax withheld . . . . . .

8 Form 1099-R. Enter distributions from pensions, annuities, retirement/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 in line 8b) .

f Federal income tax withheld . . . .

g State income tax withheld . . . . .

h Local income tax withheld . . . . .

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, 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 ▶

General Instructions 

Section references are to the Internal Revenue Code.

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) 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 Form W-2, Form W-2c, or Form 

1099-R from your employer or payer before contacting the IRS or 

filing Form 4852. If you do not receive the missing or corrected form 

from your employer or payer by February 14, you may call the IRS 

at 1-800-829-1040 for assistance. You must provide your name, 

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

number, and dates of employment, and your employer's or payer's 

name, address (including ZIP code), and phone number. The IRS 

will contact the employer or payer for you and request the missing 

form. The IRS also will send you a Form 4852. If you do not 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.

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. 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 

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

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

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. 

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: 

For Paperwork Reduction Act Notice, see page 2. Cat. No. 42058U Form 4852 (Rev. 12-2010) 
Form 4852 (Rev. 12-2010) Page 2 

• 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.

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 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. 

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. 

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. 

TIP If the year reported on line 4 is after 2010, leave line 7d 

blank.

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. 

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. 

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 in line 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. 

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 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 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.