Illinois Substitute for Unobtainable Form W-2

Substitute for Unobtainable Form W-2
2021 IL-4852, Substitute for Unobtainable Form W-2
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*62412191W*

Illinois Department of Revenue

IL-4852
Substitute for Unobtainable Form W-2
Attach this form to your Form IL-1040

	
	

Step 1: Read this information first

IL Attachment No. 5

What must I attach to Form IL-4852?

Who should file Form IL-4852?
You should file Form IL-4852, Substitute for Unobtainable Form W-2,
if you did not receive or were not able to obtain a Form W-2, Wage
and Tax Statement, from your employer showing that Illinois Income
Tax was withheld from your wages. However, you should not use this
form to correct the information on your Form W-2. You must contact
your employer for a corrected Form W-2.
You should only file Form IL-4852 after you have given your
employer sufficient time to mail your Form W-2 and after you have
exhausted all efforts to obtain one.
You must complete a separate Form IL-4852, filling in the information
in all steps, for each Form W-2 not received.

You must attach proof of wages and withholding, such as copies of
check stubs or a letter from your employer, on company letterhead.
	Your check stubs or letter should include the following information:
•	 	your name,
•		 your Social Security number,
• 		 tax year,
•	 	amount of Illinois Income Tax withheld, and
•	 	total wages.
We will accept a copy of your properly completed federal
Form 4852, along with any required attachments, as proof of your
Illinois Income Tax withheld from your wages.

Step 2: Provide the following information
	 1	 Name

	 3	 Address	

				

–

	2	 SSN

–

Street address

		

			
Social Security number		
City					State		ZIP

Step 3: Identify your employer
	 4	 Name of employer

–

	 6	 FEIN (if known)

Federal employer identification number

							

5		Address

		
	

	

Street address

		
City		
		

7	 Owner or contact person

(

State 	

		
	

­­­­­

)

	 8	 Phone number ­­­­­
ZIP							

Step 4: Complete the following
	 9	 Enter the tax year for which you are filing this form. 				
	10	 Enter

the total amount of gross wages that your employer paid you. 	

9	

	10	
______________ 00

	11	 Enter the total amount of Illinois Income Tax that your employer withheld from your wages.
		 Include this amount on the Illinois Income Tax withheld line of your Form IL-1040. 	11	
______________ 00
12		 How did you determine the total amount of gross wages and the total amount of Illinois Income Tax withheld?

13		 State the reason your employer did not give you your Form W-2.

14		 Explain your efforts to obtain your Form W-2.

Step 5: Sign below

Under penalties of perjury, I state that I have examined this form and any attachments and, to the best of my knowledge, they are true, correct, and
complete.

	

Your signature		
IL-4852 (R-12/19)
Printed by authority of the State of Illinois, web only, 1.

	

Date	

(

)

Daytime phone number

This form is authorized as outlined under the Illinois Income Tax Act. Disclosure of
this information is required. Failure to provide information could result in a penalty.

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