IRS Form 4852 "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."

IRS Form 4852 Printable Pdf
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This version of the form is not currently in use and is provided for reference only.
Download this version of IRS Form 4852 for the current year.

What Is IRS Form 4852?

This is a tax form that was released by the Internal Revenue Service (IRS) - a subdivision of the U.S. Department of the Treasury on September 1, 2018. As of today, no separate filing guidelines for the form are provided by the IRS.

Form Details:

  • A 2-page form available for download in PDF;
  • Actual and valid for filing 2021 taxes;
  • Editable, printable, and free;
  • Fill out the form in our online filing application.

Download a fillable version of IRS Form 4852 through the link below or browse more documents in our library of IRS Forms.

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Download IRS Form 4852 "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."

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4852
Substitute for Form W-2, Wage and Tax Statement, or
Form 1099-R, Distributions From Pensions, Annuities, Retirement
Form
or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
(Rev. September 2018)
OMB No. 1545-0074
Attach to Form 1040 or 1040X.
▶
Department of the Treasury
Go to www.irs.gov/Form4852 for the latest information.
Internal Revenue Service
▶
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,
,
Form W-2 OR
I have been unable to obtain (or have received an incorrect)
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
TIN (if known)
7
Form W-2. Enter wages, tips, other compensation, and taxes withheld.
a Wages, tips, and other compensation
f
State income tax withheld .
.
.
.
.
b Social security wages
.
.
.
.
(Name of state) .
c Medicare wages and tips
.
.
.
g Local income tax withheld .
.
.
.
.
d Social security tips
.
.
.
.
.
(Name of locality)
e Federal income tax withheld
h Social security tax withheld .
.
.
.
.
.
.
i
Medicare tax withheld
.
.
.
.
.
.
8
Form 1099-R. Enter distributions from pensions, annuities, retirement or 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 .
(Name of state) .
d Total distribution .
.
.
.
.
.
h Local income tax withheld .
.
.
.
.
e Capital gain (included in line 8b) .
(Name of locality)
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.
General Instructions
If you received an incorrect Form W-2 or Form 1099-R, you
should always attempt to have your employer or payer issue a
Section references are to the Internal Revenue Code.
corrected form before filing Form 4852.
Future developments. For the latest information about
Note: Retain a copy of Form 4852 for your records. To help protect
developments related to Form 4852, such as legislation enacted
your social security benefits, keep a copy of Form 4852 until you
after it was published, go to www.irs.gov/Form4852.
begin receiving social security benefits, just in case there is a
question about your work record and/or earnings in a particular
Purpose of form. Form 4852 serves as a substitute for Forms W-2,
year. After September 30 following the date shown on line 4, you
W-2c, and 1099-R and is completed by you or your representatives
when (a) your employer or payer doesn’t issue you a Form W-2 or
may use your Social Security online account to verify wages
reported by your employers. Please visit www.SSA.gov/myaccount.
Form 1099-R or (b) an employer or payer has issued an incorrect
Or, you may contact your local SSA office to verify wages reported
Form W-2 or Form 1099-R. Attach this form to the back of your
income tax return before any supporting forms or schedules.
by your employer.
Will I need to amend my return? If you receive a Form W-2, Form
You should always attempt to get your Form W-2, Form W-2c, or
W-2c, or Form 1099-R after your return is filed with Form 4852, and
Form 1099-R from your employer or payer before contacting the
the information you receive indicates that the information reported
IRS or filing Form 4852. If you don’t receive the missing or
on your original return is incorrect, you must amend your return by
corrected form from your employer or payer by the end of February,
filing Form 1040X, Amended U.S. Individual Income Tax Return.
you may call the IRS at 800-829-1040 for assistance. You must
You are responsible for filing your income tax return with accurate
provide your name, address (including ZIP code), phone number,
information regardless of whether you receive a Form W-2, Form
social security number, and dates of employment. You also must
W-2c, or Form 1099-R and regardless of whether the information on
provide your employer’s or payer’s name, address (including ZIP
any forms received is correct.
code), and phone number. The IRS will contact your employer or
payer and request the missing form. The IRS also will send you a
Penalties. The IRS will challenge the claims of individuals who
Form 4852. If you don’t receive the missing form in sufficient time to
attempt to avoid or evade their federal tax liability by using Form
file your income tax return timely, you may use the Form 4852 that
4852 in a manner other than as prescribed. Potential penalties for
the IRS sent you.
the improper use of Form 4852 include:
4852
For Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 9-2018)
Cat. No. 42058U
4852
Substitute for Form W-2, Wage and Tax Statement, or
Form 1099-R, Distributions From Pensions, Annuities, Retirement
Form
or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
(Rev. September 2018)
OMB No. 1545-0074
Attach to Form 1040 or 1040X.
▶
Department of the Treasury
Go to www.irs.gov/Form4852 for the latest information.
Internal Revenue Service
▶
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,
,
Form W-2 OR
I have been unable to obtain (or have received an incorrect)
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
TIN (if known)
7
Form W-2. Enter wages, tips, other compensation, and taxes withheld.
a Wages, tips, and other compensation
f
State income tax withheld .
.
.
.
.
b Social security wages
.
.
.
.
(Name of state) .
c Medicare wages and tips
.
.
.
g Local income tax withheld .
.
.
.
.
d Social security tips
.
.
.
.
.
(Name of locality)
e Federal income tax withheld
h Social security tax withheld .
.
.
.
.
.
.
i
Medicare tax withheld
.
.
.
.
.
.
8
Form 1099-R. Enter distributions from pensions, annuities, retirement or 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 .
(Name of state) .
d Total distribution .
.
.
.
.
.
h Local income tax withheld .
.
.
.
.
e Capital gain (included in line 8b) .
(Name of locality)
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.
General Instructions
If you received an incorrect Form W-2 or Form 1099-R, you
should always attempt to have your employer or payer issue a
Section references are to the Internal Revenue Code.
corrected form before filing Form 4852.
Future developments. For the latest information about
Note: Retain a copy of Form 4852 for your records. To help protect
developments related to Form 4852, such as legislation enacted
your social security benefits, keep a copy of Form 4852 until you
after it was published, go to www.irs.gov/Form4852.
begin receiving social security benefits, just in case there is a
question about your work record and/or earnings in a particular
Purpose of form. Form 4852 serves as a substitute for Forms W-2,
year. After September 30 following the date shown on line 4, you
W-2c, and 1099-R and is completed by you or your representatives
when (a) your employer or payer doesn’t issue you a Form W-2 or
may use your Social Security online account to verify wages
reported by your employers. Please visit www.SSA.gov/myaccount.
Form 1099-R or (b) an employer or payer has issued an incorrect
Or, you may contact your local SSA office to verify wages reported
Form W-2 or Form 1099-R. Attach this form to the back of your
income tax return before any supporting forms or schedules.
by your employer.
Will I need to amend my return? If you receive a Form W-2, Form
You should always attempt to get your Form W-2, Form W-2c, or
W-2c, or Form 1099-R after your return is filed with Form 4852, and
Form 1099-R from your employer or payer before contacting the
the information you receive indicates that the information reported
IRS or filing Form 4852. If you don’t receive the missing or
on your original return is incorrect, you must amend your return by
corrected form from your employer or payer by the end of February,
filing Form 1040X, Amended U.S. Individual Income Tax Return.
you may call the IRS at 800-829-1040 for assistance. You must
You are responsible for filing your income tax return with accurate
provide your name, address (including ZIP code), phone number,
information regardless of whether you receive a Form W-2, Form
social security number, and dates of employment. You also must
W-2c, or Form 1099-R and regardless of whether the information on
provide your employer’s or payer’s name, address (including ZIP
any forms received is correct.
code), and phone number. The IRS will contact your employer or
payer and request the missing form. The IRS also will send you a
Penalties. The IRS will challenge the claims of individuals who
Form 4852. If you don’t receive the missing form in sufficient time to
attempt to avoid or evade their federal tax liability by using Form
file your income tax return timely, you may use the Form 4852 that
4852 in a manner other than as prescribed. Potential penalties for
the IRS sent you.
the improper use of Form 4852 include:
4852
For Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 9-2018)
Cat. No. 42058U
2
Form 4852 (Rev. 9-2018)
Page
Line 8—Form 1099-R. To the extent you received a Form 1099-R
• Accuracy-related penalties equal to 20% of the amount of taxes
with correct information, complete line 8 by entering that correct
that should have been paid,
information reported on your Form 1099-R. If you don’t have
• Civil fraud penalties equal to 75% of the amount of taxes that
complete and accurate information from a Form 1099-R, use a
should have been paid, and
distribution statement from your plan trustee to help complete
• A $5,000 civil penalty for filing a frivolous return or submitting a
line 8. For additional information, get Form 1099-R and the
Instructions for Forms 1099-R and 5498.
specified frivolous submission as described by section 6702.
a—Gross distribution. Enter the total amount you received for
Specific Instructions
the year as a gross distribution.
b—Taxable amount. Enter the taxable amount of your
Lines 1 through 3. Enter your name, social security number, and
distribution.
current address including street, city, state, and ZIP code.
c—Taxable amount not determined. Check this box if you are
Line 4. Enter the year for which Form W-2 or Form 1099-R wasn’t
unable to compute your taxable distribution. If you check this box,
received or was incorrect.
leave line 8b blank.
Line 5. Enter your employer’s or payer’s name, address, and ZIP
d—Total distribution. Check this box only if the payment shown
code.
on line 8a is a total distribution.
Line 6. Enter your employer’s or payer’s taxpayer identification
e—Capital gain (included in line 8b). Enter the capital gain on
number (TIN), if known. If you had the same employer or payer in
your lump-sum distributions that you also included on line 8b. Only
the prior year, use the employer identification number (EIN) shown
certain individuals can elect to treat lump-sum distributions as a
on the prior year’s Form W-2 or Form 1099-R. If you don’t know the
capital gain on Form 4972, Tax on Lump-Sum Distributions. See the
EIN, but you know a different TIN associated with the employer or
Instructions for Form 4972 for details.
payer, such as a social security number (SSN), you may enter that
TIN.
f—Federal income tax withheld. Enter the amount of federal
income tax withheld.
Line 7—Form W-2. To the extent you received a Form W-2 with
correct information, complete line 7 by entering that correct
g—State income tax withheld. Enter the amount of state income
information reported on your Form W-2. If you don’t have complete
tax withheld. Enter the name of the state.
and accurate information from a Form W-2, use your final pay stub
h—Local income tax withheld. Enter the amount of local income
to help complete line 7. For additional information, get Form W-2
tax withheld. Enter the name of the locality.
and the General Instructions for Forms W-2 and W-3.
i—Employee contributions. Enter your investment in the
a—Wages, tips, and other compensation. Enter your total
contract (after-tax contributions), if any, recovered tax free this year.
wages received (include wages, noncash income, tips reported, and
j—Distribution codes. Enter the distribution code or codes that
all other compensation before deductions for taxes, insurance, etc.).
apply. If you are reporting more than one code, separate the codes
b—Social security wages. Enter your total wages subject to
with a comma. See the Instructions for Forms 1099-R and 5498 for
employee social security tax. Don’t include social security tips and
a complete list of codes. If your distribution was from a traditional
allocated tips.
IRA, SEP IRA, or SIMPLE IRA, write “IRA,” “SEP,” or “SIMPLE” in
c—Medicare wages and tips. Enter your total wages and tips
the right margin.
subject to Medicare tax. This amount may be required to be entered
Line 9. Explain how you determined the amounts on line 7 or 8. For
on Form 8959, Additional Medicare Tax. See the Form 1040
example, tell us if you estimated the amounts, used your pay stubs,
instructions to determine if you are required to complete Form 8959.
or used a statement reporting your distribution.
d—Social security tips. Enter the tips you reported to your
Line 10. Explain what you did to get Form W-2, Form 1099-R, or
employer for the year. The total of lines 7b and 7d can’t exceed the
Form W-2c from your employer or payer.
social security wage base for the year reported on line 4. The total
amount of tips received during the year should be included on line
Paperwork Reduction Act Notice. We ask for the information on
7a. You can find the social security wage base for any given year at
Form 4852 to carry out the Internal Revenue laws of the United
www.SSA.gov/OACT/COLA/cbb.html. The social security wage
States. You are required to give us the information. We need it to
base for a given year can be found in the Publication 15 (Circular E),
figure and collect the right amount of tax.
Employer’s Tax Guide, for that year, usually in the “What’s New”
section at the beginning of the publication.
You are not required to provide the information requested on a
form that is subject to the Paperwork Reduction Act unless the
e—Federal income tax withheld. Enter the amount of federal
form displays a valid OMB control number. Books or records
income taxes withheld from your wages for the year. Include the
relating to a form or its instructions must be retained as long as
20% excise tax withheld on excess parachute payments on this
their contents may become material in the administration of any
line.
Internal Revenue law. Generally, tax returns and return information
f—State income tax withheld. Enter the amount of state income
are confidential, as required by section 6103.
tax withheld from wages for the year. Enter the name of the state.
The average time and expenses required to complete and file this
g—Local income tax withheld. Enter the amount of local income
form vary depending on individual circumstances. For the
tax withheld from wages for the year. Enter the name of the locality.
estimated averages, see the instructions for your income tax return.
h—Social security tax withheld. Enter the amount of social
If you have suggestions for making Form 4852 simpler, we would
security tax withheld (not including the employer’s share), including
be happy to hear from you. See the instructions for your income tax
social security tax on tips.
return.
i—Medicare tax withheld. Enter the amount of Medicare tax
withheld (not including the employer’s share). This amount
includes the 1.45% Medicare tax withheld on all Medicare wages
and tips you report on line 7c, as well as the 0.9% Additional
Medicare Tax withheld on any of those Medicare wages and tips
above $200,000. For more information on Additional Medicare Tax,
go to www.irs.gov/AdMT.
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