Connecticut Substitute for Forms W-2 and 1099-R

Substitute for Forms W-2 and 1099-R
Form CT-4852
Department of Revenue Services
State of Connecticut
(Rev. 12/23)

Form CT-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.
Purpose
Complete Form CT-4852, if you have been unable to obtain (or have received an incorrect) Form W-2, Wage and Tax Statement,
or Form 1099‑R (Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.)
from an employer or payer and have notified the Internal Revenue Service.
A separate Form CT-4852 must be completed for each missing or incorrect Form W-2 or Form 1099‑R.

General Information
First name and middle initial	

Last name		

Mailing address	

Number and street	

Apt. No.	

City, town, or post office	

State	

ZIP Code

	

Social Security Number

__ __ __

••
•

__ __

Telephone number

		

••
•

__ __ __ __

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Substitute Form Information
1.	 Please fill in the year at the end of this statement. I have been unable to obtain (or have received an incorrect) Form W-2
or Form 1099‑R from my employer or payer named below. The amounts shown below are my best estimates of all wages or
payments paid to me and the federal and Connecticut taxes withheld by this employer or payer during _____________ (year).
2. Name, address, city, state, and ZIP code of employer or payer	

3.	Connecticut Tax Registration # of employer or payer (if known)

	

4. Federal Employer Identification # of employer or payer (if known)

5. Federal income tax withheld	
6.	Wages, tips, other compensation	
		 or payments (See below.)

7. Connecticut income tax withheld	

8. Connecticut wages, tips, etc.

Include total wages paid, noncash payments, tips reported, and all other compensation before deductions for taxes, insurance, etc. in Box 6 and Box 8.

9.	 How did you determine the amounts in Boxes 5 through 8 above? If you received a Form W-2 showing federal wages
and federal income tax withheld, attach a copy to Form CT-4852. If you did not receive a Form W-2 but you file federal
Form 4852 to report federal wages and federal tax withheld, attach a copy of federal Form 4852 to Form CT-4852.
Do not attach Form CT-4852 to your Connecticut income tax return. Keep Form CT-4852 with your tax records. You may
be asked by the Department of Revenue Services (DRS) to provide a copy of Form CT-4852 at a later date.
		
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10.	Give reason Form W-2, 1099‑R, or W-2C, Corrected Wage and Tax Statement, was not furnished by the employer or
payer, if known, and explain your efforts to get it.
		
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Declaration: I declare under penalty of law that I have examined this return or document (including any accompanying schedules and
statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering
a false return or document to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
Signature ________________________________________________________________ Date	 _________________________________________

Visit us at portal.ct.gov/DRS for more information.