8854 Expatriation Information Statement

U.S. Individual Income Tax Return

8854

U.S. Individual Income Tax Return

OMB: 1545-0074

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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).
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INSTRUCTIONS TO PRINTERS
FORM 4852, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
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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

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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)


File Typeapplication/pdf
File Title2005 Form 1040
SubjectU.S. Individual Income Tax Return
AuthorSE:W:CAR:MP
File Modified2006-12-30
File Created2006-12-30

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