EFTA01222721.pdf

Fom4852 Substitute for Form W-2, Wage and Tax Statement, or Form 1099-R, Distributions From Pensions, Annuities, Retirement (Rev. September 2018) or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. OMB No. 1545-0074 Deparbnent of the Treasury ► Attach to Form 1040 or 1040X. Internal Revenue Semite ► Go to www.irs.gov/Form4852 for the latest information. 1 Narne(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 payers 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 in 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 Font 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 visit wvnv.SSAgov/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 1040X, 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 also must 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. Farm 4852 (Rev. 9-2018) EFTA01222721