EFTA01222720.pdf

Substitute for Form W-2, Wage and Tax Statement, or Fomi 4852 Form 1099-R, Distributions From Pensions, Annuities, Retirement (Rev. September 2017) or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. OMB No. 15,15-0074 Department al the Treasury ► Attach to Form 1040, 1040A, 1040-EZ, or 1040X. Internal Revenue Service ► Go to www.lts.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 payer's identification number (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 h Local income tax withheld d Total distribution i Employee contributions e Capital gain (included in line 8b) 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. For Paperwork Reduction Act Notice, see page 2. Cat. No. 42058U Form 4852 (Rev. 9-2017) EFTA01222720