Substitute for Form W-2, Wage and Tax Statement, or           
Form   4852                 Form 1099-R, Distributions From Pensions, Annuities, Retirement  
(Rev. September 2019)         or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.                               OMB No. 1545-0074
                                               ▶
Department of the Treasury                        Attach to Form 1040, 1040-SR, or 1040-X.
Internal Revenue Service                ▶ Go to www.irs.gov/Form4852 for the latest information.
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, or Form W-2c, Corrected Wage and Tax Statement. 

General Instructions                                                     If you received an incorrect Form W-2 or Form 1099-R, you 
                                                                       should always attempt to have your employer or payer issue a 
Section references are to the Internal Revenue Code.                   corrected form before filing Form 4852. 
Future developments. For the latest information about                  Note: Retain a copy of Form 4852 for your records. To help protect 
developments related to Form 4852, such as legislation enacted         your social security benefits, keep a copy of Form 4852 until you 
after it was published, go to www.irs.gov/Form4852.                    begin receiving social security benefits, just in case there is a 
Purpose of form. Form 4852 serves as a substitute for Forms W-2,       question about your work record and/or earnings in a particular 
W-2c, and 1099-R and is completed by you or your representatives       year. After September 30 following the date shown on line 4, you 
when (a) your employer or payer doesn’t issue you a Form W-2 or        may use your Social Security online account to verify wages 
Form 1099-R or (b) an employer or payer has issued an incorrect        reported by your employers. Please visitwww.SSA.gov/myaccount. 
Form W-2 or Form 1099-R. Attach this form to the back of your          Or, you may contact your local SSA office to verify wages reported 
income tax return before any supporting forms or schedules.            by your employer. 
You should always attempt to get your Form W-2, Form W-2c, or          Will I need to amend my return? If you receive a Form W-2, Form 
Form 1099-R from your employer or payer before contacting the          W-2c, or Form 1099-R after your return is filed with Form 4852, and 
IRS or filing Form 4852. If you don’t receive the missing or           the information you receive indicates that the information reported 
corrected form from your employer or payer by the end of February,     on your original return is incorrect, you must amend your return by 
you may call the IRS at 800-829-1040 for assistance. You must          filing Form 1040-X, Amended U.S. Individual Income Tax Return. 
provide your name, address (including ZIP code), phone number,         You are responsible for filing your income tax return with accurate 
social security number, and dates of employment. You must also         information regardless of whether you receive a Form W-2, Form 
provide your employer’s or payer’s name, address (including ZIP        W-2c, or Form 1099-R and regardless of whether the information on 
code), and phone number. The IRS will contact your employer or         any forms received is correct.
payer and request the missing form. The IRS also will send you a       Penalties. The IRS will challenge the claims of individuals who  
Form 4852. If you don’t receive the missing form in sufficient time to attempt to avoid or evade their federal tax liability by using Form  
file your income tax return timely, you may use the Form 4852 that     4852 in a manner other than as prescribed. Potential penalties for 
the IRS sent you.                                                      the improper use of Form 4852 include: 
For Paperwork Reduction Act Notice, see page 2.                          Cat. No. 42058U                           Form  4852  (Rev. 9-2019) 

Form 4852 (Rev. 9-2019)                                                                                                             Page  2 
• Accuracy-related penalties equal to 20% of the amount of taxes       Line 8—Form 1099-R. To the extent you received a Form 1099-R 
that should have been paid,                                            with correct information, complete line 8 by entering that correct 
• Civil fraud penalties equal to 75% of the amount of taxes that       information reported on your Form 1099-R. If you don’t have 
should have been paid, and                                             complete and accurate information from a Form 1099-R, use a 
                                                                       distribution statement from your plan trustee to help complete     
• A $5,000 civil penalty for filing a frivolous return or submitting a line 8. For additional information, get Form 1099-R and the 
specified frivolous submission as described by section 6702.           Instructions for Forms 1099-R and 5498.
                                                                         a—Gross distribution. Enter the total amount you received for 
Specific Instructions                                                  the year as a gross distribution. 
Lines 1 through 3. Enter your name, social security number, and          b—Taxable amount. Enter the taxable amount of your 
current address including street, city, state, and ZIP code.           distribution. 
Line 4. Enter the year for which Form W-2 or Form 1099-R wasn’t          c—Taxable amount not determined. Check this box if you are 
received or was incorrect.                                             unable to compute your taxable distribution. If you check this box, 
Line 5. Enter your employer’s or payer’s name, address, and ZIP        leave line 8b blank. 
code.                                                                    d—Total distribution. Check this box only if the payment shown 
Line 6. Enter your employer’s or payer’s taxpayer identification       on line 8a is a total distribution. 
number (TIN), if  known. If you had the same employer or payer in        e—Capital gain (included on line 8b). Enter the capital gain on 
the prior year, use the employer identification number (EIN) shown     your lump-sum distributions that you also included on line 8b. Only 
on the prior year’s Form W-2 or Form 1099-R. If you don’t know the     certain individuals can elect to treat lump-sum distributions as a 
EIN, but you know a different TIN associated with the employer or      capital gain on Form 4972, Tax on Lump-Sum Distributions. See the 
payer, such as a social security number (SSN), you may enter that      Instructions for Form 4972 for details. 
TIN.                                                                     f—Federal income tax withheld. Enter the amount of federal  
Line 7—Form W-2. To the extent you received a Form W-2 with            income tax withheld. 
correct information, complete line 7 by entering that correct            g—State income tax withheld. Enter the amount of state income 
information reported on your Form W-2. If you don’t have complete      tax withheld. Enter the name of the state.
and accurate information from a Form W-2, use your final pay stub        h—Local income tax withheld. Enter the amount of local income 
to help complete line 7. For additional information, get Form W-2      tax withheld. Enter the name of the locality.
and the General Instructions for Forms W-2 and W-3. 
                                                                         i—Employee contributions. Enter your investment in the 
a—Wages, tips, and other compensation. Enter your total                contract (after-tax contributions), if any, recovered tax free this year. 
wages received (include wages, noncash income, tips reported, and 
all other compensation before deductions for taxes, insurance, etc.).    j—Distribution codes. Enter the distribution code or codes that 
                                                                       apply. If you are reporting more than one code, separate the codes 
b—Social security wages. Enter your total wages subject to             with a comma. See the Instructions for Forms 1099-R and 5498 for 
employee social security tax. Don’t include social security tips and   a complete list of codes. If your distribution was from a traditional 
allocated tips.                                                        IRA, SEP IRA, or SIMPLE IRA, write “IRA,” “SEP,” or “SIMPLE” in 
c—Medicare wages and tips. Enter your total wages and tips             the right margin. 
subject to Medicare tax. This amount may be required to be entered     Line 9.Explain how you determined the amounts on line 7 or 8. For 
on Form 8959, Additional Medicare Tax. See the Instructions for        example, tell us if you estimated the amounts, used your pay stubs, 
Forms 1040 and 1040-SR to determine if you are required to             or used a statement reporting your distribution. 
complete Form 8959. 
d—Social security tips. Enter the tips you reported to your            Line 10. Explain what you did to get Form W-2, Form 1099-R, or  
employer for the year. The total of lines 7b and 7d can’t exceed the   Form W-2c from your employer or payer. 
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     Paperwork Reduction Act Notice. We ask for the information on 
7a. You can find the social security wage base for any given year at   Form 4852 to carry out the Internal Revenue laws of the United 
www.SSA.gov/OACT/COLA/cbb.html. The social security wage               States. You are required to give us the information. We need it to 
base for a given year can be found in Pub. 15 (Circular E),            figure and collect the right amount of tax. 
Employer’s Tax Guide, for that year, usually under What’s New at         You are not required to provide the information requested on a  
the beginning of the publication.                                      form that is subject to the Paperwork Reduction Act unless the  
e—Federal income tax withheld. Enter the amount of federal             form displays a valid OMB control number. Books or records  
income taxes withheld from your wages for the year. Include the        relating to a form or its instructions must be retained as long as  
20% excise tax withheld on excess parachute payments on this           their contents may become material in the administration of any  
line.                                                                  Internal Revenue law. Generally, tax returns and return information 
                                                                       are confidential, as required by section 6103. 
f—State income tax withheld. Enter the amount of state income 
tax withheld from wages for the year. Enter the name of the state.       The average time and expenses required to complete and file this 
                                                                       form vary depending on individual circumstances. For the  
g—Local income tax withheld. Enter the amount of local income          estimated averages, see the instructions for your income tax return. 
tax withheld from wages for the year. Enter the name of the locality. 
                                                                         If you have suggestions for making Form 4852 simpler, we would  
h—Social security tax withheld. Enter the amount of social             be happy to hear from you. See the instructions for your income tax 
security tax withheld (not including the employer’s share), including  return. 
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.