Form 4852, Substitute for Form W-2 or 1099-R Completed Form Examples and Samples

Explore a detailed example of Form 4852, a substitute for a missing W-2. This guide demonstrates filling out the form with estimated wages, federal tax withheld, and essential employee and employer information. Ideal for tax season preparation.
Form 4852, Substitute for Form W-2 or 1099-R has a moderate Form Complexity Index of 53/100 — Instafill’s AI completes it in under a minute.
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Completed Form 4852 for a missing W-2

Form 4852 Example – Replacement for Missing W-2

How this form was filled:

This example demonstrates how to complete Form 4852 when a W-2 is missing. It includes estimated wages, federal income tax withheld, and other necessary details. The employee’s details and employer’s information are filled in with estimated amounts, including a signature and date.

Information used to fill out the document:

  • Employee Name: John Smith
  • Employee Social Security Number: 987-65-4320
  • Tax Year: 2024
  • Employer's Name: ABC Industries, Inc.
  • Employer's Address: 456 Corporate Drive, Business City, USA
  • Employer's Identification Number (EIN): 98-7654321
  • Estimated Wages: $45,000
  • Estimated Federal Income Tax Withheld: $4,500
  • Signature: John Smith
  • Date: 02/15/2025

What this filled form sample shows:

  • Steps to create a substitute for a missing W-2
  • Estimated amounts for wages and tax withheld
  • Detailed employer information section
  • Mandatory signature and date fields completed

Form specifications and details:

Use Case: Substitute for a missing or incorrect W-2
Form Number: 4852
Filing Year: 2025
Categories: HR forms, 1099 forms, VA forms
Completed Form 4852 for a missing W-2