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

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

Extracted from PDF file 2023-massachusetts-form-m-4852.pdf, last modified September 2019

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More about the Massachusetts Form M-4852 Other TY 2023

We last updated the Substitute for Form W-2, Wage and Tax Statement in February 2024, so this is the latest version of Form M-4852, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form M-4852 directly from TaxFormFinder. You can print other Massachusetts tax forms here.

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Other Massachusetts Other Forms:

TaxFormFinder has an additional 126 Massachusetts income tax forms that you may need, plus all federal income tax forms.

Form Code	Form Name
Form M-4	Massachusetts Employee's Withholding Exemption Certificate
Form M-3	Reconciliation of Massachusetts Income Taxes Withheld for Employers
Form 355SBC	Small Business Corporation Excise Return Tax Return
Form M-941	Employer’s Return of Income Taxes Withheld
Form 355SV	Taxation of Ships and Vessels

Download all MA tax forms View all 127 Massachusetts Income Tax Forms

Form Sources:

Massachusetts usually releases forms for the current tax year between January and April. We last updated Massachusetts Form M-4852 from the Department of Revenue in February 2024.

Show Sources >

Historical Past-Year Versions of Massachusetts Form M-4852

We have a total of seven past-year versions of Form M-4852 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:

2023 Form M-4852

2022 Form M-4852

2021 Form M-4852

2020 Form M-4852

2019 Form M-4852

2018 Form M-4852

M-4852

2017 Form M-4852

M-4852

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While we do our best to keep our list of Massachusetts Income Tax Forms up to date and complete, we cannot be held liable for errors or omissions. Is the form on this page out-of-date or not working? Please let us know and we will fix it ASAP.