1350                                         STATE OF SOUTH CAROLINA
                                               DEPARTMENT OF  REVENUE
                                                                                                         SC4852
                                                                                                         (Rev. 7/15/19)
                                SUBSTITUTE FOR FORM W2
dor.sc.gov                                                                                                  3236
                                WAGE AND TAX STATEMENT
                                File this form with your South Carolina Income Tax Return.
                                        Complete a separate form for each employer.
Your full name (type or print)                                              Social Security Number

Address                                                 City                State                    ZIP

Your phone number                      Does this employer have your current Period worked for this employer
                                       address?
                                                        Yes        No
Employer's name

Employer's address                                      City                State                    ZIP

Employer's Federal Identification Number (if known)

Employer's phone number                Type of business 

Wages paid in:                 Amount of wages        Estimated South Carolina Income Taxes withheld Tax year 
cash           check
Which form you are referencing?                                    Check applicable box:
                                                                   1. Employer has not given me the forms.
1. W2                           3. W2C                             2. Forms given to me by employer are incorrect.
2. W2P                          4. 1099                            3. Forms are lost.
                                                                   4. Forms given to me by employer are illegible.
Attach copies of pay stubs, military leave and earnings statement, or other documentation to support your claim.
                                        REQUIRED INFORMATION
Explain how you calculated the amount of wages received and the amount of estimated South Carolina Income Taxes withheld.

Explain the efforts you made to get an accurate W2, W2P, W2C, 1099.

I declare that this return and all attachments are true, correct, and complete to the best of my knowledge and belief. To willfully furnish a 
false or fraudulent statement to the SCDOR is a crime.

                   Signature                                                                         Date

Social Security Privacy Act Disclosure 
It is mandatory that you provide your Social Security Number on this tax form if you are an individual taxpayer. 42 U.S.C. 405(c)(2)(C)(i) 
permits a state to use an individual's Social Security Number as means of identification in administration of any tax. SC Regulation 
117-201 mandates that any person required to make a return to the SCDOR must provide identifying numbers, as prescribed, for 
securing proper identification. Your Social Security Number is used for identification purposes. 

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