Form Wh-4852 - Indiana Substitute For Form W-2 Or Form 1099-R
ADVERTISEMENT
1Instructions for Form WH-4852
You must send a separate Form WH-4852 for each Form W-2 not received.
We will accept a copy of your Federal Form 4852 as proof of your Indiana Income Tax withheld from your wages,
otherwise you will need to complete the Indiana Form WH-4852 below.
Taxpayer Information
Enter the tax year of the missing W-2 or 1099-R form.
Enter your Social Security Number, Name, Address, City, State,
and Zip Code.
Enter wages, compensations, and taxes withheld,
Employer or Payer Information
or enter 1099-R information
Enter Employer’s or payer’s ID Number (if known), Name,
Complete Lines A through F using the amounts from your
Address, City, State, and Zip Code.
Federal Form 4852.
Enter the period of time (month, day, year) you worked for your employer during the tax year.
How did you determine amounts of wages and withholding shown on your Federal Form 4852?
If from a pay stub, Check box; if “Other”, Check box and please explain.
Attach photocopy of payroll check stub(s) or other document(s) to verify the Indiana withholding amount(s) claimed.
Please note: A refund cannot be claimed based upon estimated withholding credits.
For assistance call (317) 233-4016, or you may e-mail the
Sign and Date Form.
Department at:
gov/dor/contact/email.html
Indiana Department of Revenue
Form WH-4852
Tax Year
Indiana Substitute for Form W-2 or Form 1099-R
State Form 48326
(R/ 01-03)
You must send a separate Form WH-4852 for each Form W-2 not received.
We will accept your Federal Form 4852 as proof showing your Indiana Income Tax withheld from your wages.
Taxpayer Information
Enter wages, compensations, and taxes withheld,
or enter 1099-R information.
Social Security Number
Complete the following lines using the amounts from your Federal
Name
Form 4852.
Form 4852 Line #
Address
A. Wages ....................................
7(A)a
City/State/Zip Code
B. State Tax Withheld .........................
g
Employer or Payer Information
Name of State
Employer’s or payer’s ID, FID,
or TID Number (if known)
C. Local Tax Withheld .......................
h
Name of Locality
Name
D. Gross Distribution .................
7(B)1
Address
E. Taxable Amount ...........................
2a
City/State/Zip Code
F. State tax withheld ..........................
5
/
/
/
/
Period worked for employer during the tax year: From
To
How did you determine the amounts used on Federal Form 4852?
Paycheck Stub
Other explain:
Attach photocopy of payroll check stub (s) or other document(s) to verify the Indiana withholding amount(s) claimed.
Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true,
correct, and complete.
Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-r, Distributions Form Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contacts, Ets. - 1998
Financial
Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-r - Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Form 4852 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Form 3525 - California Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-r, Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc.
Financial
Related Categories
Parent category: Financial