Form 4852

(Rev. January 2007)

Substitute for Form W-2, Wage and Tax Statement, or Form
1099-R, Distributions From Pensions, Annuities, Retirement or OMB No. 1545-0074
Department of the Treasury
Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
Internal Revenue Service © Attach to Form 1040, 1040A, 1040-EZ, or 1040X.
1 Type or print your first name and middle initial. Last name 2 Social security number (SSN)

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 g State income tax withheld
b Social security wages (Name of state)
c Medicare wages and tips h Local income tax withheld
d Advance EIC payment (Name of locality)
e Social security tips i Social security tax withheld
f Federal income 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 f Federal income tax withheld

b Taxable amount g State income tax withheld
c Taxable amount not determined h Local income tax withheld
d Total distribution i Employee contributions
e Capital gain (included in 8b) 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.

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.
Sign
Here Signature © Date ©

Purpose of form. Form 4852 serves as a substitute for Forms September 30 following the date shown on line 4, you may
W-2, W-2c, and 1099-R and is completed by taxpayers or their contact your local SSA office to verify wages reported by your
representatives when (a) their employer or payer does not give employers.
them a Form W-2 or Form 1099-R, or (b) when an employer or Will I need to amend my return? If you receive a Form W-2,
payer has issued an incorrect Form W-2 or Form 1099-R. Attach Form W-2c, or Form 1099-R, after your return is filed with Form
this form to your income tax return. 4852, and the information differs from the information reported
You should always attempt to get Form W-2 or Form 1099-R on your return, you must amend your return by filing Form
from your employer or payer before contacting the IRS or filing 1040X, Amended U.S. Individual Income Tax Return.
Form 4852. After February 14, you may call the IRS at Penalties. The IRS will challenge the claims of individuals who
1-800-829-1040 if you still have not received Form W-2 or Form attempt to avoid or evade their federal tax liability by using Form
1099-R. Generally, do not file Form 4852 before April 15. 4852 in a manner other than as prescribed. Potential penalties
If you received an incorrect Form W-2 or Form 1099-R, you for the improper use of Form 4852 include:
should always attempt to have your employer or payer issue a ● Accuracy-related penalties equal to 20 percent of the amount
corrected form before filing Form 4852. of taxes that should have been paid,
Note. Retain a copy of Form 4852 for your records. Check your ● Civil fraud penalties equal to 75 percent of the amount of
Social Security Statement (received at least a full year after the taxes that should have been paid, and
date shown on line 4) against Form 4852. If the earnings you
reported on Form 4852 are not shown in the statement, you ● A $5,000 civil penalty for filing a frivolous return or submitting
should contact the Social Security Administration (SSA) at the a specified frivolous submission as described by section 6702 of
telephone number shown on the statement. Alternatively, after the Internal Revenue Code.

For Paperwork Reduction Act Notice, see page 2. Cat. No. 42058U Form 4852 (Rev. 1-2007)
Form 4852 (Rev. 1-2007) Page 2

Instructions a—Gross distribution. Enter the total amount you received for
the year as a gross distribution.
Lines 1–3. Enter your name, social security number (SSN), and
current address including street, city, state, and ZIP code. b—Taxable amount. Enter the taxable amount of your
distribution.
Line 4. Enter the year you received taxable income from which
federal income taxes were withheld and Form W-2 or c—Taxable amount not determined. Mark an “X” in this box
Form 1099-R was not received or was incorrect. if you are unable to compute your taxable distribution. If you
mark this box, leave line 8b blank.
Line 5. Enter your employer’s or payer’s name, address, and ZIP
code. d—Total distribution. Mark an “X” in this box only if the
payment shown on line 8a is a total distribution.
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, e—Capital gain (included in 8b). Enter the capital gain on
use the identification number shown on that Form W-2 or your lump-sum distributions that you also included in line 8b.
Form 1099-R. Only certain individuals can elect to treat lump-sum distributions
as a capital gain on Form 4972, Tax on Lump-Sum Distributions.
Line 7—Form W-2. Complete line 7 by entering information See the Instructions for Form 4972 for details.
reported on Form W-2. If possible, use your final pay stub to
complete line 7. For additional information, get Form W-2 and f—Federal income tax withheld. Enter the amount of federal
the Instructions for Forms W-2 and W-3. income tax withheld.
a—Wages, tips, and other compensation. Enter your total g—State income tax withheld. Enter the amount of state
wages received (include wages, noncash income, tips reported, income tax withheld.
and all other compensation before deductions for taxes, h—Local income tax withheld. Enter the amount of local
insurance, etc.). income tax withheld.
b—Social security wages. Enter your total wages subject to i—Employee contributions. Enter your investment in the
employee social security tax. Do not include social security tips contract (after-tax contributions), if any, recovered tax free this
and allocated tips. year.
c—Medicare wages and tips. Enter your total wages and tips j—Distribution codes. Enter the distribution code or codes
subject to Medicare tax. that apply. If you are reporting more than one code, separate the
d—Advance EIC payment. Enter the total amount you codes with a comma. See the Instructions for Forms 1099-R and
received as advance earned income credit (EIC) payments. 5498 for a complete list of codes. If your distribution was from
an IRA, SEP, or SIMPLE plan, write “IRA,” “SEP,” or “SIMPLE” in
e—Social security tips. Enter the tips you reported to your the right margin.
employer for the year. The total of lines 7b and 7e cannot
exceed the social security wage base for the year reported in Line 9. Explain how you determined the amounts on line 7 or 8.
line 4. The total amount of tips received during the year should For example, tell us if you estimated the amounts, used your pay
be included in line 7a. stubs, or used a statement reporting your distribution.
f—Federal income tax withheld. Enter the amount of federal Line 10. Explain what you did to get Form W-2, Form 1099-R, or
income taxes withheld from your wages for the year. This Form W-2c from your employer or payer.
amount should not be reduced by advance EIC payments.
Include the 20% excise tax withheld on excess parachute
payments on this line. Paperwork Reduction Act Notice. We ask for the information
on Form 4852 to carry out the Internal Revenue laws of the
g—State income tax withheld. Enter the amount of state United States. You are required to give us the information. We
income tax withheld from wages for the year. Enter the name of need it to figure and collect the right amount of tax.
the state.
You are not required to provide the information requested on a
h—Local income tax withheld. Enter the amount of local form that is subject to the Paperwork Reduction Act unless the
income tax withheld from wages for the year. Enter the name of form displays a valid OMB control number. Books or records
the locality. relating to a form or its instructions must be retained as long as
i—Social security tax withheld. Enter the amount of social their contents may become material in the administration of any
security tax withheld (not including the employer’s share), Internal Revenue law. Generally, tax returns and return
including social security tax on tips. This amount should not be information are confidential, as required by section 6103.
reduced by advance EIC payments. The average time and expenses required to complete and file
j—Medicare tax withheld. Enter the amount of Medicare tax this form vary depending on individual circumstances. For the
withheld (not including the employer’s share). This amount estimated averages, see the instructions for your income tax
should not be reduced by advance EIC payments. return.
Line 8—Form 1099-R. Complete line 8 by entering information If you have suggestions for making Form 4852 simpler, we would
reported on Form 1099-R. If possible, use the distribution be happy to hear from you. See the instructions for your income
statement from your plan trustee to complete line 8. For tax return.
additional information, get Form 1099-R and the Instructions for
Forms 1099-R and 5498.