Form WH-4852 Instructions You must send a separate Form WH-4852 for each Form W-2 not received. We will accept a copy of your federal Form 4852 as proof of your Indiana Income Tax withheld from your wages, otherwise you will need to complete the Indiana Form WH-4852 below. Taxpayer Information Enter your Social Security Number, Name, Address, City, State and Zip Code. Enter the tax year of the missing W-2 or 1099-R form. Enter wages, compensation and taxes withheld, or enter 1099-R information. Complete Lines A through F using the amounts from your federal Form 4852. Employer or Payer Information Enter employer’s or payer’s ID Number (if known), Name, Address, City, State and Zip Code. Enter the period of time (month, day, year) you worked for your employer during the tax year. How did you determine amounts of wages and withholding shown on your federal Form 4852? If from a paycheck stub, check box; if “Other”, check box and please explain. Attach photocopy of payroll check stub(s) or other document(s) to verify the Indiana withholding amount(s) claimed. Please note: A refund cannot be claimed based upon estimated withholding credits. Sign, date form and attach to income tax return. For assistance call (317) 233-4016, or you may e-mail the Department of Revenue: www.in.gov/dor/contact/email.html Indiana Department of Revenue Form WH-4852 Tax Year Indiana Substitute for Form W-2 or Form 1099-R State Form 48326 (R2 / 5-06) You must send a separate Form WH-4852 for each Form W-2 not received. We will accept a copy of your federal Form 4852 as proof of your Indiana Income Tax withheld from your wages. Enter wages, compensations and taxes withheld, or enter 1099-R information. Taxpayer Information Social Security Number Complete the following lines using the amounts from your federal Form 4852 line numbers. Name Address A. Wages ................................... 7 (A) a City/State/Zip Code B. State tax withheld............................ g Name of state C. Local tax withheld ...........................h Name of locality Employer or Payer Information Employer’s or payer’s ID, FID or TID Number (if known) D. Gross distribution ................. 7 (B)1 Name E. Taxable amount ..............................2a Address F. State tax withheld ...........................5 City/State/Zip Code G. Local tax withheld ..........................6 Period worked for employer during the tax year: From / / To / / How did you determine the amounts used on federal Form 4852? Paycheck Stub Other - Explain: Attach photocopy of payroll check stub(s) or other documents(s) to verify the Indiana withholding amount(s) claimed. 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 Date American LegalNet, Inc. www.FormsWorkflow.com