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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
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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)
File Type | application/pdf |
File Title | 2005 Form 1040 |
Subject | U.S. Individual Income Tax Return |
Author | SE:W:CAR:MP |
File Modified | 2006-12-30 |
File Created | 2006-12-30 |