Form CT-4852 Substitute for Form W-2, Wage and Tax Statement, or Form 1099r, Distribution From Pensions, Annuities, Retirement or Profi T-Sharing Plans, Iras, Insurance Contracts, Etc. - Connecticut

Form CT-4852 or the "Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r, Distribution From Pensions, Annuities, Retirement Or Profi T-sharing Plans, Iras, Insurance Contracts, Etc." is a form issued by the Connecticut Department of Revenue Services.

Download a PDF version of the Form CT-4852 down below or find it on the Connecticut Department of Revenue Services Forms website.

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Department of Revenue Services
For DRS Use Only
State of Connecticut
450 Columbus Blvd
Form CT-4852
Hartford CT 06103-1837
Substitute for Form W-2, Wage and Tax Statement, or
(Rev. 12/17)
Form 1099R, Distributions From Pensions, Annuities,
Retirement or Profi t-Sharing Plans, IRAs, Insurance Contracts, Etc.
Purpose
Complete Form CT-4852, if you have been unable to obtain (or have received an incorrect) Form W-2, Wage and Tax
Statement, or Form 1099R (Distributions From Pensions, Annuities, Retirement or Profi t-Sharing Plans, IRAs, Insurance
Contracts, etc.) from an employer or payer and have notifi ed the Internal Revenue Service.
A separate Form CT-4852 must be completed for each missing or incorrect Form W-2 or Form 1099R.
General Information
First name and middle initial
Last name
Social Security Number
__ __ __ __ __ __ __ __ __
Mailing address
Number and street
Apt. No.
Telephone number
(
)
City, town, or post offi ce
State
ZIP Code
Substitute Form Information
1. Please fi ll in the year at the end of this statement. I have been unable to obtain (or have received an incorrect) Form W-2
or Form 1099R from my employer or payer named below. The amounts shown below are my best estimates of all wages or
payments paid to me and the federal and Connecticut taxes withheld by this employer or payer during
(year).
____________
2. Name, address, city, state, and ZIP code of employer or payer
3. Connecticut Tax Registration # of employer or payer (if known)
4. Federal Employer Identifi cation # of employer or payer (if known)
5. Federal income tax withheld
6. Wages, tips, other compensation
7. Connecticut income tax withheld
8. Connecticut wages, tips, etc.
or payments (See below.)
Include total wages paid, noncash payments, tips reported, and all other compensation before deductions for taxes, insurance, etc. in Box 6 and Box 8.
9. How did you determine the amounts in Boxes 5 through 8 above? If you received a Form W-2 showing federal wages
and federal income tax withheld, attach a copy to Form CT-4852. If you did not receive a Form W-2 but you fi le federal
Form 4852 to report federal wages and federal tax withheld, attach a copy of federal Form 4852 to Form CT-4852.
Do not attach Form CT-4852 to your Connecticut income tax return. Keep Form CT-4852 with your tax records. You may
be asked by the Department of Revenue Services (DRS) to provide a copy of Form CT-4852 at a later date.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
10. Give reason Form W-2, 1099R, or W-2C, Corrected Wage and Tax Statement, was not furnished by the employer or
payer, if known, and explain your efforts to get it.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Declaration: I declare under penalty of law that I have examined this return or document (including any accompanying schedules and
statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering
a false return or document to DRS is a fi ne of not more than $5,000, or imprisonment for not more than fi ve years, or both.
Signature
Date
_______________________________________________________________
________________________________________
Department of Revenue Services
For DRS Use Only
State of Connecticut
450 Columbus Blvd
Form CT-4852
Hartford CT 06103-1837
Substitute for Form W-2, Wage and Tax Statement, or
(Rev. 12/17)
Form 1099R, Distributions From Pensions, Annuities,
Retirement or Profi t-Sharing Plans, IRAs, Insurance Contracts, Etc.
Purpose
Complete Form CT-4852, if you have been unable to obtain (or have received an incorrect) Form W-2, Wage and Tax
Statement, or Form 1099R (Distributions From Pensions, Annuities, Retirement or Profi t-Sharing Plans, IRAs, Insurance
Contracts, etc.) from an employer or payer and have notifi ed the Internal Revenue Service.
A separate Form CT-4852 must be completed for each missing or incorrect Form W-2 or Form 1099R.
General Information
First name and middle initial
Last name
Social Security Number
__ __ __ __ __ __ __ __ __
Mailing address
Number and street
Apt. No.
Telephone number
(
)
City, town, or post offi ce
State
ZIP Code
Substitute Form Information
1. Please fi ll in the year at the end of this statement. I have been unable to obtain (or have received an incorrect) Form W-2
or Form 1099R from my employer or payer named below. The amounts shown below are my best estimates of all wages or
payments paid to me and the federal and Connecticut taxes withheld by this employer or payer during
(year).
____________
2. Name, address, city, state, and ZIP code of employer or payer
3. Connecticut Tax Registration # of employer or payer (if known)
4. Federal Employer Identifi cation # of employer or payer (if known)
5. Federal income tax withheld
6. Wages, tips, other compensation
7. Connecticut income tax withheld
8. Connecticut wages, tips, etc.
or payments (See below.)
Include total wages paid, noncash payments, tips reported, and all other compensation before deductions for taxes, insurance, etc. in Box 6 and Box 8.
9. How did you determine the amounts in Boxes 5 through 8 above? If you received a Form W-2 showing federal wages
and federal income tax withheld, attach a copy to Form CT-4852. If you did not receive a Form W-2 but you fi le federal
Form 4852 to report federal wages and federal tax withheld, attach a copy of federal Form 4852 to Form CT-4852.
Do not attach Form CT-4852 to your Connecticut income tax return. Keep Form CT-4852 with your tax records. You may
be asked by the Department of Revenue Services (DRS) to provide a copy of Form CT-4852 at a later date.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
10. Give reason Form W-2, 1099R, or W-2C, Corrected Wage and Tax Statement, was not furnished by the employer or
payer, if known, and explain your efforts to get it.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Declaration: I declare under penalty of law that I have examined this return or document (including any accompanying schedules and
statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering
a false return or document to DRS is a fi ne of not more than $5,000, or imprisonment for not more than fi ve years, or both.
Signature
Date
_______________________________________________________________
________________________________________

Download Form CT-4852 Substitute for Form W-2, Wage and Tax Statement, or Form 1099r, Distribution From Pensions, Annuities, Retirement or Profi T-Sharing Plans, Iras, Insurance Contracts, Etc. - Connecticut

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