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R 2010) Department of the Treasury Internal Revenue Service OMB No. 1545-0074 Attach to Form 1040, 1040A, 1040-EZ, or 1040X. 1 Name(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.

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