4852 Substitute for Form W-2, Wage and Tax Statement or Form

Form

4852

(Rev. September 2020)

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.

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0074

Attachment
Sequence No. 04

▶ Attach to Form 1040, 1040-SR, or 1040-X.
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,
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.
5 Employer’s or payer’s name, address, and ZIP code
6 Employer’s or payer’s
TIN (if known)
7

8

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) .
g Local income tax withheld
c Medicare wages and tips . . .
d Social security tips . . . . .
(Name of locality)
e Federal income tax withheld . .
h Social security tax withheld
i Medicare tax withheld .

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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) .
h Local income tax withheld . . . . .
d Total distribution . . . . . .
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 (original or corrected), or Form W-2c, Corrected Wage and Tax Statement.

General Instructions
Section references are to the Internal Revenue Code.
Future developments. For the latest information about developments
related to Form 4852, such as legislation enacted after it was published,
go to www.irs.gov/Form4852.
Purpose of form. Form 4852 serves as a substitute for Forms W-2,
W-2c, and 1099-R (original or corrected) and is completed by you or
your representatives when (a) your employer or payer doesn’t issue you
a Form W-2 or Form 1099-R, or (b) an employer or payer has issued an
incorrect Form W-2 or Form 1099-R. Attach this form to the back of
your income tax return before any supporting forms or schedules.
For Paperwork Reduction Act Notice, see page 2.

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
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.

Cat. No. 42058U

Form

4852

(Rev. 9-2020)

Form 4852 (Rev. 9-2020)

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
before filing Form 4852.
Note: Retain a copy of Form 4852 for your records. To help protect
your social security benefits, keep a copy of Form 4852 until you
begin receiving social security benefits, just in case there is a question
about your work record and/or earnings in a particular year. After
September 30 following the date shown on line 4, you may use your
Social Security online account to verify wages reported by your
employers. Please visit www.SSA.gov/myaccount. Or, you may contact
your local SSA office to verify wages reported by your employer.
Will I need to amend my return? If you receive a Form W-2, Form
W-2c, or Form 1099-R (original or corrected) after your return is filed
with Form 4852, and the information you receive indicates that the
information reported on your original return is incorrect, you must
amend your return by filing Form 1040-X, Amended U.S. Individual
Income Tax Return. You are responsible for filing your income tax return
with accurate information regardless of whether you receive a Form
W-2, Form W-2c, or Form 1099-R (original or corrected) and regardless
of whether the information on any forms received is correct.
Penalties. The IRS will challenge the claims of individuals who attempt
to avoid or evade their federal tax liability by using Form 4852 in a
manner other than as prescribed. Potential penalties for the improper
use of Form 4852 include:
• Accuracy-related penalties equal to 20% of the amount of taxes that
should have been paid,
• Civil fraud penalties equal to 75% of the amount of taxes that should
have been paid, and
• A $5,000 civil penalty for filing a frivolous return or submitting a
specified frivolous submission as described by section 6702.

Specific Instructions
Lines 1 through 3. Enter your name, social security number, and
current address including street, city, state, and ZIP code.
Line 4. Enter the year for which Form W-2 or Form 1099-R wasn’t
received or was incorrect.
Line 5. Enter your employer’s or payer’s name, address, and ZIP code.
Line 6. Enter your employer’s or payer’s taxpayer identification number
(TIN), if known. If you had the same employer or payer in the prior year,
use the employer identification number (EIN) shown on the prior year’s
Form W-2 or Form 1099-R. If you don’t know the EIN, but you know a
different TIN associated with the employer or payer, such as a social
security number (SSN), you may enter that TIN.
Line 7—Form W-2. To the extent the Form W-2 you received reported
correct information, complete line 7 by entering that correct information.
If you don’t have complete and accurate information from a Form W-2,
use your final pay stub to help complete line 7. For additional
information, get Form W-2 and the General Instructions for Forms W-2
and W-3.
a—Wages, tips, and other compensation. Enter your total wages
received (include wages, noncash income, tips reported, and all other
compensation before deductions for taxes, insurance, etc.).
b—Social security wages. Enter your total wages subject to
employee social security tax. Don’t include social security tips and
allocated tips.
c—Medicare wages and tips. Enter your total wages and tips
subject to Medicare tax. This amount may be required to be entered on
Form 8959, Additional Medicare Tax. See the Instructions for Forms
1040 and 1040-SR to determine if you are required to complete Form
8959.
d—Social security tips. Enter the tips you reported to your employer
for the year. The total of lines 7b and 7d can’t exceed the 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 7a. You can find the
social security wage base for any given year at www.SSA.gov/OACT/
COLA/cbb.html. The social security wage base for a given year can be
found in Pub. 15 (Circular E), Employer’s Tax Guide, for that year,
usually under What’s New at the beginning of the publication.
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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f—State income tax withheld. Enter the amount of state income tax
withheld from wages for the year. Enter the name of the state.
g—Local income tax withheld. Enter the amount of local income tax
withheld from wages for the year. Enter the name of the locality.
h—Social security tax withheld. Enter the amount of social security
tax withheld (not including the employer’s share), including social
security tax on tips.
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.
Line 8—Form 1099-R. To the extent the Form 1099-R you received
reported correct information, complete line 8 by entering that correct
information. If you don’t have complete and accurate information from a
Form 1099-R, use a distribution statement from your plan trustee to help
complete line 8. For additional information, get Form 1099-R and the
Instructions for Forms 1099-R and 5498.
a—Gross distribution. Enter the total amount you received for the
year as a gross distribution.
b—Taxable amount. Enter the taxable amount of your distribution.
c—Taxable amount not determined. Check this box if you are
unable to compute your taxable distribution. If you check this box, leave
line 8b blank.
d—Total distribution. Check this box only if the payment shown on
line 8a is a total distribution.
e—Capital gain (included on line 8b). Enter the capital gain on your
lump-sum distributions that you also included on line 8b. Only certain
individuals can elect to treat lump-sum distributions as a capital gain on
Form 4972, Tax on Lump-Sum Distributions. See the Instructions for
Form 4972 for details.
f—Federal income tax withheld. Enter the amount of federal income
tax withheld.
g—State income tax withheld. Enter the amount of state income tax
withheld. Enter the name of the state.
h—Local income tax withheld. Enter the amount of local income tax
withheld. Enter the name of the locality.
i—Employee contributions. Enter your investment in the contract
(after-tax contributions), if any, recovered tax free this year.
j—Distribution codes. Enter the distribution code or codes that
apply. If you are reporting more than one code, separate the codes with
a comma. See the Instructions for Forms 1099-R and 5498 for a
complete list of codes. If your distribution was from a traditional IRA,
SEP IRA, or SIMPLE IRA, write “IRA,” “SEP,” or “SIMPLE” in the right
margin.
Line 9. Explain how you determined the amounts on line 7 or 8. For
example, tell us if you estimated the amounts, used your pay stubs, or
used a statement reporting your distribution.
Line 10. Explain any attempts made to get the missing or corrected
Form W-2, Form 1099-R, or Form W-2c from your employer or payer.
Paperwork Reduction Act Notice. We ask for the information on Form
4852 to carry out the Internal Revenue laws of the United States. You
are required to give us the information. We need it to figure and collect
the right amount of tax.
You are not required to provide the information requested on a form
that is subject to the Paperwork Reduction Act unless the form displays
a valid OMB control number. Books or records relating to a form or its
instructions must be retained as long as their contents may become
material in the administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by section
6103.
The average time and expenses required to complete and file this
form vary depending on individual circumstances. For the estimated
averages, see the instructions for your income tax return.
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.