- Use this form when you are missing a Form W-2 and still need to report the wages and Indiana withholding for your Indiana return.
- Prepare a separate WH-4852 for each missing W-2 (do not combine multiple missing W-2s on one WH-4852).
- A copy of your federal Form 4852 can be used as proof of Indiana withholding from wages; if you aren’t using the federal substitute, complete this Indiana form instead.
What To Gather Before You Start
- Your personal identifying details and current mailing address.
- Employer/payer identifying details (ID number if known) and address.
- Proof documents such as paycheck stubs, payroll summaries, or other records showing Indiana withholding (because estimated withholding cannot be used to claim a refund).
How To Complete The Form (Top To Bottom)
Form Title Area
Indiana Substitute For Form W-2 Or Form 1099-R
This identifies the purpose of the form: it replaces missing wage or certain retirement distribution reporting documents for Indiana filing purposes.
You Must Send A Separate Form WH-4852 For Each Form W-2 Not Received
If you’re missing two W-2s, you complete two WH-4852s, one per employer/W-2.
We Will Accept A Copy Of Your Federal Form 4852 As Proof… Otherwise Complete Indiana Form WH-4852
If you already prepared the federal substitute (Form 4852) and it supports the Indiana withholding you’re claiming, you can include that copy; if not, fill out this Indiana substitute form fully.
Tax Year
Tax Year
Enter the tax year for the missing W-2 or 1099-R information you’re substituting for (for example, the year shown on the missing form).
Taxpayer Information Section
Social Security Number
Enter your SSN.
Name
Enter your full name.
Address
Enter your street address.
City/State/Zip Code
Enter your city, state, and ZIP code.
Employer Or Payer Information Section
Employer’s Or Payer’s ID, FID Or TID Number (If Known)
Enter the employer/payer’s identifying number if you know it (don’t guess if you truly don’t have it).
Name
Enter the employer or payer’s name.
Address
Enter the employer or payer’s address.
City/State/Zip Code
Enter the employer/payer’s city, state, and ZIP code.
Wage Or 1099-R Data Section (Lines A Through G)
This section tells you to use the figures from your federal Form 4852 line references, and it’s where you enter wages/withholding or 1099‑R amounts.
A. Wages (Reference: “7 (A) a”)
Enter your wage amount using the corresponding line reference shown.
B. State Tax Withheld (Reference: “g”) + Name Of State
Enter the state withholding amount and write the state name (for Indiana purposes, this supports the state withholding you’re claiming).
C. Local Tax Withheld (Reference: “h”) + Name Of Locality
Enter any local tax withheld and name the locality tied to that local withholding.
D. Gross Distribution (Reference: “7 (B)1”)
If you’re entering 1099‑R information, enter the gross distribution amount using the line reference shown.
E. Taxable Amount (Reference: “2a”)
Enter the taxable portion of the distribution using the line reference shown.
F. State Tax Withheld (Reference: “5”)
Enter state tax withheld related to the distribution using the line reference shown.
G. Local Tax Withheld (Reference: “6”)
Enter any local tax withheld related to the distribution using the line reference shown.
Period Worked
Period Worked For Employer During The Tax Year: From / / To / /
Enter the start and end dates (month/day/year format) you worked for the employer during that tax year.
How You Determined The Amounts
How Did You Determine The Amounts Used On Federal Form 4852?
Choose the method you used to calculate the wage/withholding numbers you’re reporting.
Paycheck Stub (Checkbox)
Check this if the amounts came from paycheck stub(s).
Other – Explain (Checkbox + Line)
Check this if you used a different source (for example, payroll history report) and briefly explain what records you used.
Attachments Requirement
Attach Photocopy Of Payroll Check Stub(s) Or Other Document(s) To Verify Indiana Withholding Amount(s) Claimed
Attach copies of documents that back up the Indiana withholding you entered, because the claim must be verifiable.
Please Note: A Refund Cannot Be Claimed Based Upon Estimated Withholding Credits
Do not enter “guessed” withholding—refunds must be supported by actual records.
Signature Statement
Under Penalties Of Perjury… True, Correct, And Complete
This is your certification that the information is accurate to the best of your knowledge.
Signature
Sign the form.
Date
Enter the date you sign.
How To File It (Submission)
- Sign and date the WH-4852 and attach it to your Indiana income tax return when you file.
- Include the supporting documents (paycheck stubs or other proof) with the return submission so the withholding claim can be verified.