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Substitute for Form W-2, Wage and Tax Statement, or
OMB No. 1545-0074
Form 4852 Form 1099-R, Distributions From Pensions, Annuities, Retirement
(Rev. September 2020) or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
Department of the Treasury Attach to Form 1040, 1040-SR, or 1040-X. Attachment
▶
Sequence No. 04
Internal Revenue Service ▶ 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 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) .
c Medicare wages and tips . . . g Local income tax withheld . . . . .
d Social security tips . . . . . (Name of locality)
e Federal income tax withheld . . h Social security tax withheld . . . . .
i Medicare tax withheld . . . . . .

8 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) .
d Total distribution . . . . . . h Local income tax withheld . . . . .
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 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
Section references are to the Internal Revenue Code. contacting the IRS or filing Form 4852. If you don’t receive the missing
Future developments. For the latest information about developments or corrected form from your employer or payer by the end of February,
related to Form 4852, such as legislation enacted after it was published, you may call the IRS at 800-829-1040 for assistance. You must provide
go to www.irs.gov/Form4852. your name, address (including ZIP code), phone number, social security
Purpose of form. Form 4852 serves as a substitute for Forms W-2, number, and dates of employment. You must also provide your
W-2c, and 1099-R (original or corrected) and is completed by you or employer’s or payer’s name, address (including ZIP code), and phone
your representatives when (a) your employer or payer doesn’t issue you number. The IRS will contact your employer or payer and request the
a Form W-2 or Form 1099-R, or (b) an employer orpayer has issued an missing form. The IRS will also send you a Form 4852. If you don’t
incorrect Form W-2 or Form 1099-R. Attachthis form to the back of receive the missing form in sufficient time to file your income tax return
your income tax return before any supporting forms or schedules. timely, you may use the Form 4852 that the IRS sent you.

For Paperwork Reduction Act Notice, see page 2. Cat. No. 42058U Form 4852 (Rev. 9-2020)

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Form 4852 (Rev. 9-2020) Page 2
If you received an incorrect Form W-2 or Form 1099-R, you should f—State income tax withheld. Enter the amount of state income tax
always attempt to have your employer or payer issue a corrected form withheld from wages for the year. Enter the name ofthe state.
before filing Form 4852. g—Local income tax withheld. Enter the amount of localincome tax
Note: Retain a copy of Form 4852 for your records. To help protect withheld from wages for the year. Enter the name ofthe locality.
your social securitybenefits, keep a copy of Form 4852 until you h—Social security tax withheld. Enter the amount of socialsecurity
begin receiving social security benefits, just in case there is a question tax withheld (not including the employer’s share), including social
about your work record and/or earnings in a particular year. After security tax on tips.
September 30 following the date shown on line 4, you may use your
Social Security online account to verify wages reported by your i—Medicare tax withheld. Enter the amount of Medicare tax
employers. Please visit www.SSA.gov/myaccount. Or, you may contact withheld (not including the employer’s share). This amount includes the
your local SSA office to verify wages reported by your employer. 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
Will I need to amend my return? If you receive a Form W-2, Form of those Medicare wages and tips above $200,000. For more
W-2c, or Form 1099-R (original or corrected) after your return is filed information on Additional Medicare Tax, go to www.irs.gov/AdMT.
with Form 4852, and the information you receive indicates that the
information reported on your original return is incorrect, you must Line 8—Form 1099-R. To the extent the Form 1099-R you received
amend your return by filing Form 1040-X, Amended U.S. Individual reported correct information, complete line 8 by entering that correct
Income Tax Return. You are responsible for filing your income tax return information. If you don’t have complete and accurate information from a
with accurate information regardless of whether you receive a Form Form 1099-R, use a distribution statement from your plan trustee to help
W-2, Form W-2c, or Form 1099-R (original or corrected) and regardless complete line 8. For additional information, get Form 1099-R and the
of whether the information on any forms received is correct. Instructions for Forms 1099-R and 5498.
Penalties. The IRS will challenge the claims of individuals whoattempt a—Gross distribution. Enter the total amount you received for the
to avoid or evade their federal tax liability by using Form4852 in a year as a gross distribution.
manner other than as prescribed. Potential penalties for the improper b—Taxable amount. Enter the taxable amount of your distribution.
use of Form 4852 include: c—Taxable amount not determined. Check this boxif you are
• Accuracy-related penalties equal to 20% of the amount of taxes that unable to compute your taxable distribution. If you check this box, leave
should have been paid, line 8b blank.
• Civil fraud penalties equal to 75% of the amount of taxes that should d—Total distribution. Check this box only if the payment shown on
have been paid, and line 8a is a total distribution.
• A $5,000 civil penalty for filing a frivolous return or submitting a e—Capital gain (included on line 8b). Enter the capital gain on your
specified frivolous submission as described by section 6702. 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
Specific Instructions Form 4972, Tax on Lump-Sum Distributions. See the Instructions for
Form 4972 for details.
Lines 1 through 3. Enter your name, social security number, and
current address including street, city, state, and ZIP code. f—Federal income tax withheld. Enter the amount of federalincome
tax withheld.
Line 4. Enter the year for which Form W-2 or Form 1099-R wasn’t
received or was incorrect. g—State income tax withheld. Enter the amount of state income tax
withheld. Enter the name of the state.
Line 5. Enter your employer’s or payer’s name, address, and ZIPcode.
h—Local income tax withheld. Enter the amount of local income tax
Line 6. Enter your employer’s or payer’s taxpayer identification number withheld. Enter the name of the locality.
(TIN), ifknown. If you had the same employer or payer in the prior year,
use the employer identification number (EIN) shown on the prior year’s i—Employee contributions. Enter your investment in the contract
Form W-2 or Form 1099-R. If you don’t know the EIN, but you know a (after-tax contributions), if any, recovered tax free this year.
different TIN associated with the employer or payer, such as a social j—Distribution codes. Enter the distribution code or codes that
security number (SSN), you may enter that TIN. apply. If you are reporting more than one code, separate the codes with
Line 7—Form W-2. To the extent the Form W-2 you received reported a comma. See the Instructions for Forms 1099-R and5498 for a
correct information, complete line 7 by entering that correct information. complete list of codes. If your distribution was from a traditional IRA,
If you don’t have complete and accurate information from a Form W-2, SEP IRA, or SIMPLE IRA, write “IRA,” “SEP,” or “SIMPLE” in the right
use your final pay stub to help complete line 7. For additional margin.
information, get Form W-2 and the General Instructions for Forms W-2 Line 9. Explain how you determined the amounts on line 7 or 8.For
and W-3. example, tell us if you estimated the amounts, used your pay stubs, or
a—Wages, tips, and other compensation. Enter your totalwages used a statement reporting your distribution.
received (include wages, noncash income, tips reported, and all other Line 10. Explain any attempts made to get the missing or corrected
compensation before deductions for taxes,insurance, etc.). Form W-2, Form 1099-R, or Form W-2c from your employer or payer.
b—Social security wages. Enter your total wages subject to
employee social security tax. Don’t include social security tipsand Paperwork Reduction Act Notice. We ask for the information on Form
allocated tips. 4852 to carry out the Internal Revenue laws of the United States. You
c—Medicare wages and tips. Enter your total wages and tips are required to give us the information. We need it to figure and collect
subject to Medicare tax. This amount may be required to be entered on the right amount of tax.
Form 8959, Additional Medicare Tax. See the Instructions for Forms You are not required to provide the information requested on a form
1040 and 1040-SR to determine if you are required to complete Form that is subject to the Paperwork Reduction Act unless the form displays
8959. a valid OMB control number. Books or records relating to a form or its
d—Social security tips. Enter the tips you reported to youremployer instructions must be retained as long as their contents may become
for the year. The total of lines 7b and 7d can’t exceed the social security material in the administration of any Internal Revenue law. Generally, tax
wage base for the year reported on line 4. The total amount of tips returns and return information are confidential, as required by section
received during the year should be included on line 7a. You can find the 6103.
social security wage base for any given year at www.SSA.gov/OACT/ The average time and expenses required to complete and file this
COLA/cbb.html. The social security wage base for a given year can be form vary depending on individual circumstances. For the estimated
found in Pub. 15 (Circular E), Employer’s Tax Guide, for that year, averages, see the instructions for your income tax return.
usually under What’s New at the beginning of the publication. If you have suggestions for making Form 4852 simpler, we would be
e—Federal income tax withheld. Enter the amount of federal happy to hear from you. See the instructions for your income tax return.
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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