Indiana Substitute for Form W-2 or Form 1099-R - Form WH-4852 - Instructions

Sep 19, 2026

Instructions for completing Indiana Form WH-4852, an Indiana substitute used when a Federal Form W-2 is not received. The form requires taxpayer details, employer or payer information, and the tax year for the missing W-2 or 1099-R. Applicants must enter wage and withholding amounts drawn from Federal Form 4852, complete lines A through F, state the period worked, and explain how amounts were determined. Supporting documents must be attached, then the form signed and dated.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Taxpayer Information

Employer or Payer Information

Tax Year and Income Details

Completing Lines A Through F

Period Worked and Amount Determination

Attachments, Penalty Statement, Signature and Date

Instructions for Form WH-4852 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. Employer or Payer Information Enter Employer’s or payer’s ID Number (if known), Name, Address, City, State, and Zip Code. Enter the tax year of the missing W-2 or 1099-R form. Enter wages, compensations, and taxes withheld, or enter 1099-R information Complete Lines A through F using the amounts from your Federal Form 4852. 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 pay 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: Arefund cannot be claimed based upon estimated withholding credits. Sign and Date Form.􀀆 For assistance call (317) 233-4016, or you may e-mail the [Department at:](Department at: www.in. gov/dor/contactus/email.html)[ www.in. gov/dor/contactus/email.html](Department at: www.in. gov/dor/contactus/email.html) Form WH-4852 State Form 48326 Indiana Department of Revenue Indiana Substitute for Form W-2 or Form 1099-R (R/ 01-03) You must send a separate Form WH-4852 for each Form W-2 not received. Tax Year We will accept your Federal Form 4852 as proof showing your Indiana Income Tax withheld from your wages. Taxpayer Information | Name | | --- | | Address | | City/State/Zip Code | Employer or Payer Information Employer’s or payer’s ID, FID, or TID Number (if known) | Name | | --- | | Address | | City/State/Zip Code | Enter wages, compensations, and taxes withheld, or enter 1099-R information. Complete the following lines using the amounts from your Federal Form 4852. Form 4852 Line \# A. Wages .................................... 7(A)a B. State Tax Withheld ......................... g Name of State C. Local Tax Withheld ....................... h Name of Locality D. Gross Distribution 7(B)1 E. Taxable Amount ........................... 2a F. State tax withheld .......................... 5 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 document(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

FAQs

When is Form WH-4852 required?

Send a separate Form WH-4852 for each Form W-2 not received.

What documents and amounts must be used to complete WH-4852?

Use amounts from your Federal Form 4852 to complete lines A through F and provide wage, compensation, and tax withheld details.

What evidence must be attached and how should the form be signed?

Attach photocopies of payroll check stubs or other documents to verify the Indiana withholding claimed. Sign and date the form under penalties of perjury.

Sep 19, 2026

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