Form 4852, Substitute for Form W-2 or 1099-R Instructions
This form contains 34 fields organized into 7 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Determination Explanation | ||
| Determination Explanation for Lines 7 and 8 | Text |
Provide a detailed explanation of how you determined the amounts entered on lines 7 and 8 of the form.
|
| Efforts to Obtain Form Explanation | ||
| Efforts to Obtain Forms | Text |
Provide a detailed explanation of your efforts to obtain Form W-2, Form 1099-R (original or corrected), or Form W-2c, Corrected Wage and Tax Statement.
|
| Employer or Payer Information | ||
| Employer or Payer Name, Address, and ZIP Code | Text |
Please provide the full name, mailing address, and ZIP code of the employer or payer.
|
| Employer or Payer TIN | Text |
Please provide the Taxpayer Identification Number (TIN) of the employer or payer, if known.
|
| Form 1099-R Details | ||
| Gross distribution | Number |
Enter the total amount of the distribution from pensions, annuities, retirement or profit-sharing plans, IRAs, or insurance contracts. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Taxable amount | Number |
Enter the portion of the gross distribution that is taxable. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Taxable amount not determined | Checkbox |
Check this box if the taxable amount of the distribution from Form 1099-R has not been determined. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Total distribution | Checkbox |
Check this box if the amount entered is a total distribution from Form 1099-R. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Capital gain | Number |
Enter the amount of capital gain included in the taxable amount reported on line 8b. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Federal income tax withheld | Number |
Enter the amount of federal income tax withheld from the distribution. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| State income tax withheld | Number |
Enter the amount of state income tax withheld from the distribution. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| State name | Text |
Enter the name of the state where income tax was withheld. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Local income tax withheld | Number |
Enter the amount of local income tax withheld from the distribution. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Locality name | Text |
Enter the name of the locality where income tax was withheld. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Employee contributions | Number |
Enter the amount of employee contributions to the plan. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Distribution code 1 | Text |
Enter the first distribution code that applies to the distribution. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Distribution code 2 | Text |
Enter the second distribution code that applies to the distribution, if any. Fill only if 'Form 1099-R' is 'Yes'.
Depends on:
Form 1099-R
|
| Form W-2 Details | ||
| Wages, tips, and other compensation | Number |
Enter the total amount of wages, tips, and other compensation. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Social security wages | Number |
Enter the total amount of social security wages. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Medicare wages and tips | Number |
Enter the total amount of Medicare wages and tips. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Social security tips | Number |
Enter the total amount of social security tips. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Federal income tax withheld | Number |
Enter the total amount of federal income tax withheld. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| State income tax withheld | Number |
Enter the total amount of state income tax withheld. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| State name | Text |
Enter the name of the state for which income tax was withheld. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Local income tax withheld | Number |
Enter the total amount of local income tax withheld. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Locality name | Text |
Enter the name of the locality for which income tax was withheld. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Social security tax withheld | Number |
Enter the total amount of social security tax withheld. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Medicare tax withheld | Number |
Enter the total amount of Medicare tax withheld. Fill only if 'Form W-2' is 'Yes'.
Depends on:
Form W-2
|
| Tax Year and Form Type | ||
| Tax Year | Text |
Please enter the tax year for which this form is being filed, corresponding to December 31st of that year.
|
| Form W-2 | Checkbox |
Check this box if you are using Form 4852 as a substitute for an unobtained or incorrect Form W-2.
|
| Form 1099-R | Checkbox |
Check this box if you are using Form 4852 as a substitute for an unobtained or incorrect Form 1099-R.
|
| Taxpayer Information | ||
| Taxpayer Name | Text |
Enter the full name(s) of the taxpayer(s) exactly as shown on your tax return.
|
| Social Security Number | Text |
Enter your Social Security Number.
|
| Taxpayer Address | Text |
Enter your current mailing address.
|