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                                                                             *62412191W*
          Illinois Department of Revenue

          IL-4852 Substitute for Unobtainable Form W-2
          Attach this form to your Form IL-1040                                                                                                 IL Attachment No. 5
Step 1: Read this information first
Who should file Form IL-4852?                                                  What must I attach to Form IL-4852?
You should file Form IL-4852, Substitute for Unobtainable Form W-2,            You must attach proof of wages and withholding, such as copies of 
if you did not receive or were not able to obtain a Form W-2, Wage             check stubs or a letter from your employer, on company letterhead.
and Tax Statement, from your employer showing that Illinois Income               Your check stubs or letter should include the following information:
Tax was withheld from your wages. However, you should not use this              •    your name,
form to correct the information on your Form W-2. You must contact              •    your Social Security number,
your employer for a corrected Form W-2.                                         •    tax year,
                                                                                •    amount of Illinois Income Tax withheld, and 
        You should only file Form IL-4852 after you have given your             •    total wages.
employer sufficient time to mail your Form W-2 and after you have              We will accept a copy of your properly completed federal 
exhausted all efforts to obtain one.                                           Form 4852, along with any required attachments, as proof of your 
You must complete a separate Form IL-4852, filling in the information  Illinois Income Tax withheld from your wages.
in all steps, for each Form W-2 not received. 

Step 2: Provide the following information

   1 Name                                                                      3  Address 
                                                                                              Street address
  2  SSN                     –        –                                           
              Social Security number                                              City                                                       State                           ZIP

Step 3: Identify your employer

   4 Name of employer                                                          6  FEIN (if known)                     –                                                        
                                                                                                                    Federal employer identification number
      Address                                                                  7  Owner or contact person                                                                        
   5
               Street address
                                                                                                      (         )
                                                                               8  Phone number       
     City                               State                          ZIP                                                                          
Step 4: Complete the following

   9 Enter the tax year for which you are filing this form.                                                                 9                                                   
 10  Enter the total amount of gross wages that your employer paid you.                                                     10               ______________ 00
 11  Enter the total amount of Illinois Income Tax that your employer withheld from your wages. 
     Include this amount on the Illinois Income Tax withheld line of your Form IL-1040.                                     11               ______________ 00
12  How did you determine the total amount of gross wages and the total amount of Illinois Income Tax withheld?

13   State the reason your employer did not give you your Form W-2. 

14   Explain your efforts to obtain your Form W-2.

Step 5: Sign below
Under penalties of perjury, I state that I have examined this form and any attachments and, to the best of my knowledge, they are true, correct, and 
complete.
                                                                                                                                  (         )
Your signature                                                                 Date                                        Daytime phone number

          IL-4852 (R-12/19)                                                         This form is authorized as outlined under the Illinois Income Tax Act.  Disclosure of 
          Printed by authority of the State of Illinois, web only, 1.               this information is required.  Failure to provide information could result in a penalty.

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