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."

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, 2020. 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;
  • Additional instructions and information can be found on page 1 of the document;
  • 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
OMB No. 1545-0074
Form
or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
(Rev. September 2020)
Attachment
Attach to Form 1040, 1040-SR, or 1040-X.
Department of the Treasury
Sequence No. 04
Internal Revenue Service
Go to www.irs.gov/Form4852 for the latest information.
You must take the following steps before filing Form 4852
• Attempt to get your Form W-2, Form W-2c, or Form 1099-R (original or corrected) from your employer or payer before contacting the IRS or
filing Form 4852.
• If you don’t receive the missing or corrected form from your employer or payer by the end of February, you may call the IRS at
800-829-1040 for assistance. You must provide your name, address (including ZIP code), phone number, social security number, and dates of
employment. You must also provide your employer’s or payer’s name, address (including ZIP code), and phone number. The IRS will contact
your employer or payer and request the missing form. The IRS will also send you a Form 4852. If you don’t 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 to file with your return.
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 on 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.
(original or corrected)
General Instructions
You should always attempt to get your Form W-2, Form W-2c, or
Form 1099-R (original or corrected) from your employer or payer before
Section references are to the Internal Revenue Code.
contacting the IRS or filing Form 4852. If you don’t receive the missing
or corrected form from your employer or payer by the end of February,
Future developments. For the latest information about developments
you may call the IRS at 800-829-1040 for assistance. You must provide
related to Form 4852, such as legislation enacted after it was published,
your name, address (including ZIP code), phone number, social security
go to www.irs.gov/Form4852.
number, and dates of employment. You must also provide your
Purpose of form. Form 4852 serves as a substitute for Forms W-2,
employer’s or payer’s name, address (including ZIP code), and phone
W-2c, and 1099-R (original or corrected) and is completed by you or
number. The IRS will contact your employer or payer and request the
your representatives when (a) your employer or payer doesn’t issue you
missing form. The IRS will also send you a Form 4852. If you don’t
a Form W-2 or Form 1099-R, or (b) an employer or payer has issued an
receive the missing form in sufficient time to file your income tax return
incorrect Form W-2 or Form 1099-R. Attach this form to the back of
timely, you may use the Form 4852 that the IRS sent you.
your income tax return before any supporting forms or schedules.
4852
For Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 9-2020)
Cat. No. 42058U
4852
Substitute for Form W-2, Wage and Tax Statement, or
Form 1099-R, Distributions From Pensions, Annuities, Retirement
OMB No. 1545-0074
Form
or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
(Rev. September 2020)
Attachment
Attach to Form 1040, 1040-SR, or 1040-X.
Department of the Treasury
Sequence No. 04
Internal Revenue Service
Go to www.irs.gov/Form4852 for the latest information.
You must take the following steps before filing Form 4852
• Attempt to get your Form W-2, Form W-2c, or Form 1099-R (original or corrected) from your employer or payer before contacting the IRS or
filing Form 4852.
• If you don’t receive the missing or corrected form from your employer or payer by the end of February, you may call the IRS at
800-829-1040 for assistance. You must provide your name, address (including ZIP code), phone number, social security number, and dates of
employment. You must also provide your employer’s or payer’s name, address (including ZIP code), and phone number. The IRS will contact
your employer or payer and request the missing form. The IRS will also send you a Form 4852. If you don’t 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 to file with your return.
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 on 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.
(original or corrected)
General Instructions
You should always attempt to get your Form W-2, Form W-2c, or
Form 1099-R (original or corrected) from your employer or payer before
Section references are to the Internal Revenue Code.
contacting the IRS or filing Form 4852. If you don’t receive the missing
or corrected form from your employer or payer by the end of February,
Future developments. For the latest information about developments
you may call the IRS at 800-829-1040 for assistance. You must provide
related to Form 4852, such as legislation enacted after it was published,
your name, address (including ZIP code), phone number, social security
go to www.irs.gov/Form4852.
number, and dates of employment. You must also provide your
Purpose of form. Form 4852 serves as a substitute for Forms W-2,
employer’s or payer’s name, address (including ZIP code), and phone
W-2c, and 1099-R (original or corrected) and is completed by you or
number. The IRS will contact your employer or payer and request the
your representatives when (a) your employer or payer doesn’t issue you
missing form. The IRS will also send you a Form 4852. If you don’t
a Form W-2 or Form 1099-R, or (b) an employer or payer has issued an
receive the missing form in sufficient time to file your income tax return
incorrect Form W-2 or Form 1099-R. Attach this form to the back of
timely, you may use the Form 4852 that the IRS sent you.
your income tax return before any supporting forms or schedules.
4852
For Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 9-2020)
Cat. No. 42058U
2
Form 4852 (Rev. 9-2020)
Page
f—State income tax withheld. Enter the amount of state income tax
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
withheld from wages for the year. Enter the name of the state.
before filing Form 4852.
g—Local income tax withheld. Enter the amount of local income tax
Note: Retain a copy of Form 4852 for your records. To help protect
withheld from wages for the year. Enter the name of the locality.
your social security benefits, keep a copy of Form 4852 until you
h—Social security tax withheld. Enter the amount of social security
begin receiving social security benefits, just in case there is a question
tax withheld (not including the employer’s share), including social
about your work record and/or earnings in a particular year. After
security tax on tips.
September 30 following the date shown on line 4, you may use your
i—Medicare tax withheld. Enter the amount of Medicare tax
Social Security online account to verify wages reported by your
withheld (not including the employer’s share). This amount includes the
employers. Please visit www.SSA.gov/myaccount. Or, you may contact
1.45% Medicare tax withheld on all Medicare wages and tips you report
your local SSA office to verify wages reported by your employer.
on line 7c, as well as the 0.9% Additional Medicare Tax withheld on any
Will I need to amend my return? If you receive a Form W-2, Form
of those Medicare wages and tips above $200,000. For more
W-2c, or Form 1099-R (original or corrected) after your return is filed
information on Additional Medicare Tax, go to www.irs.gov/AdMT.
with Form 4852, and the information you receive indicates that the
Line 8—Form 1099-R. To the extent the Form 1099-R you received
information reported on your original return is incorrect, you must
reported correct information, complete line 8 by entering that correct
amend your return by filing Form 1040-X, Amended U.S. Individual
information. If you don’t have complete and accurate information from a
Income Tax Return. You are responsible for filing your income tax return
Form 1099-R, use a distribution statement from your plan trustee to help
with accurate information regardless of whether you receive a Form
complete line 8. For additional information, get Form 1099-R and the
W-2, Form W-2c, or Form 1099-R (original or corrected) and regardless
Instructions for Forms 1099-R and 5498.
of whether the information on any forms received is correct.
a—Gross distribution. Enter the total amount you received for the
Penalties. The IRS will challenge the claims of individuals who attempt
year as a gross distribution.
to avoid or evade their federal tax liability by using Form 4852 in a
manner other than as prescribed. Potential penalties for the improper
b—Taxable amount. Enter the taxable amount of your distribution.
use of Form 4852 include:
c—Taxable amount not determined. Check this box if you are
• Accuracy-related penalties equal to 20% of the amount of taxes that
unable to compute your taxable distribution. If you check this box, leave
should have been paid,
line 8b blank.
• Civil fraud penalties equal to 75% of the amount of taxes that should
d—Total distribution. Check this box only if the payment shown on
have been paid, and
line 8a is a total distribution.
e—Capital gain (included on line 8b). Enter the capital gain on your
• A $5,000 civil penalty for filing a frivolous return or submitting a
lump-sum distributions that you also included on line 8b. Only certain
specified frivolous submission as described by section 6702.
individuals can elect to treat lump-sum distributions as a capital gain on
Specific Instructions
Form 4972, Tax on Lump-Sum Distributions. See the Instructions for
Form 4972 for details.
Lines 1 through 3. Enter your name, social security number, and
f—Federal income tax withheld. Enter the amount of federal income
current address including street, city, state, and ZIP code.
tax withheld.
Line 4. Enter the year for which Form W-2 or Form 1099-R wasn’t
g—State income tax withheld. Enter the amount of state income tax
received or was incorrect.
withheld. Enter the name of the state.
Line 5. Enter your employer’s or payer’s name, address, and ZIP code.
h—Local income tax withheld. Enter the amount of local income tax
Line 6. Enter your employer’s or payer’s taxpayer identification number
withheld. Enter the name of the locality.
(TIN), if known. If you had the same employer or payer in the prior year,
i—Employee contributions. Enter your investment in the contract
use the employer identification number (EIN) shown on the prior year’s
(after-tax contributions), if any, recovered tax free this year.
Form W-2 or Form 1099-R. If you don’t know the EIN, but you know a
j—Distribution codes. Enter the distribution code or codes that
different TIN associated with the employer or payer, such as a social
apply. If you are reporting more than one code, separate the codes with
security number (SSN), you may enter that TIN.
a comma. See the Instructions for Forms 1099-R and 5498 for a
Line 7—Form W-2. To the extent the Form W-2 you received reported
complete list of codes. If your distribution was from a traditional IRA,
correct information, complete line 7 by entering that correct information.
SEP IRA, or SIMPLE IRA, write “IRA,” “SEP,” or “SIMPLE” in the right
If you don’t have complete and accurate information from a Form W-2,
margin.
use your final pay stub to help complete line 7. For additional
Line 9. Explain how you determined the amounts on line 7 or 8. For
information, get Form W-2 and the General Instructions for Forms W-2
example, tell us if you estimated the amounts, used your pay stubs, or
and W-3.
used a statement reporting your distribution.
a—Wages, tips, and other compensation. Enter your total wages
Line 10. Explain any attempts made to get the missing or corrected
received (include wages, noncash income, tips reported, and all other
Form W-2, Form 1099-R, or Form W-2c from your employer or payer.
compensation before deductions for taxes, insurance, etc.).
b—Social security wages. Enter your total wages subject to
Paperwork Reduction Act Notice. We ask for the information on Form
employee social security tax. Don’t include social security tips and
4852 to carry out the Internal Revenue laws of the United States. You
allocated tips.
are required to give us the information. We need it to figure and collect
c—Medicare wages and tips. Enter your total wages and tips
the right amount of tax.
subject to Medicare tax. This amount may be required to be entered on
You are not required to provide the information requested on a form
Form 8959, Additional Medicare Tax. See the Instructions for Forms
that is subject to the Paperwork Reduction Act unless the form displays
1040 and 1040-SR to determine if you are required to complete Form
a valid OMB control number. Books or records relating to a form or its
8959.
instructions must be retained as long as their contents may become
d—Social security tips. Enter the tips you reported to your employer
material in the administration of any Internal Revenue law. Generally, tax
for the year. The total of lines 7b and 7d can’t exceed the social security
returns and return information are confidential, as required by section
wage base for the year reported on line 4. The total amount of tips
6103.
received during the year should be included on line 7a. You can find the
The average time and expenses required to complete and file this
social security wage base for any given year at www.SSA.gov/OACT/
form vary depending on individual circumstances. For the estimated
COLA/cbb.html. The social security wage base for a given year can be
averages, see the instructions for your income tax return.
found in Pub. 15 (Circular E), Employer’s Tax Guide, for that year,
usually under What’s New at the beginning of the publication.
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.
e—Federal income tax withheld. Enter the amount of federal
income taxes withheld from your wages for the year. Include the 20%
excise tax withheld on excess parachute payments on this line.
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