8854 Expatriation Information Statement

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
release date on our web site (www.irs.gov).
If you have any comments on this draft form, you can
submit them to us on our web site. Include the word
DRAFT in your response. You may make comments
anonymously, or you may include your name and
e-mail address or phone number. We will be unable
to respond to all comments due to the high volume
we receive. However, we will carefully consider
each suggestion. So that we can properly consider
your comments, please send them to us within 30
days from the date the draft was posted.

1
TLS, have you
transmitted all R
text files for this
cycle update?

Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4852, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 203 mm (8") 3 279 mm (11")
PERFORATE: (NONE)

PRINTS: HEAD to HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

4852

Form
(Rev. January 2007)

Department of the Treasury
Internal Revenue Service

Action

Date

O.K. to print
Revised proofs
requested

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.
©

Signature

OMB No. 1545-0074

f
o
s
a
6
t
0
f
0
a
2
r
/
D /13
0
1

Attach to Form 1040, 1040A, 1040-EZ or 1040X.

1 Type or print your first name and middle initial.
3 Address

Last name

2 Social security number (SSN)

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.
6 Employer’s or payer’s
5 Employer’s or payer’s name, address and ZIP code
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
b
c
d
e

9

10

Gross distribution
Taxable amount
Taxable amount not determined
Total distribution
Capital gain (included in 2a)

f
g
h
i
j

Federal income tax withheld
State income tax withheld
Local income tax withheld
Employee contributions
Distribution codes

How did you determine the amounts on lines 7 and 8 above?

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

©

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date

Cat. No. 42058U

©

Form

4852

(Rev. 1-2007)