Massachusetts Substitute for Form W-2, Wage and Tax Statement

Substitute for Form W-2, Wage and Tax Statement 
Form M-4852
Massachusetts Department of Revenue

Form M-4852
Substitute for Form W-2, Wage and Tax Statement
Complete a separate form for each employer or payer for which a wage or earnings statement is not available.

Your information
1 Last name

First name

Middle initial

2 Social Security no.

3 Street address

City/Town

State

Zip

Form W-2 not received
I have been unable to obtain (or have received an incorrect) Form W-2, Wage and Tax Statement, from the employer or payer named below. The amounts shown are
my best estimates of all wages or payments paid to me and the Massachusetts taxes withheld by this employer or payer.
4 Year
5 Employer or payer’s name
Identification number
Telephone number
Employer or payer’s address

City/Town

State

Zip

Include in line 6 the total of wages paid, non-cash payments, tips reported and all other compensation before deductions for taxes, insurance, etc.
6 Wages

7 Massachusetts withholding*

8 Social Security and Medicare tax

*To calculate estimated Massachusetts withholding tax, multiply gross income from your federal Form W-2 by 5%. Call 800-829-1040 for copy of your federal Form W-2. Please
note that, for a fee, the Social Security Administration may be able to provide you with your state W-2; call them at 800-772-1213 for more information.
9 Explain how you determined the amounts in lines 6 through 8:
10 Describe your efforts to obtain Forms W-2, 1099R or W-2C, Statement of Corrected Income and Tax Amounts, from your employer or payer:
10a Fill in if at any time you were a full-time student
10b Fill in if at any time you requested that your employer or payer not withhold Massachusetts income tax because you reasonably expected to earn less than $8,000

Signature
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
For DOR use Wages

Date
Withholding

FICA

Approved

Rev. 6/19