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Get Form 4852 (rev. May 1996). Substitute For Form W-2, Wage And Tax Statement, Or Form 1099r

Ent or Profit-Sharing Plans, IRA s Insurance Contracts, Etc. OMB No. 1545-0458 Attach to Form 1040, 1040A, 1040EZ or 1040X 1 Name (First, middle, last) 3 Address (Number, street, city, state, ZIP code) 4 Please fill in the year at the end of the statement: I have been unable to obtain (or have received an incorrect) Form W-2, Wage and Tax Statement, or Form 1099R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., from my employ.

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