Form SC4852 Fillable Substitute for Form W-2 Wage and Tax Statement
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(Complete a Separate Form For Each Employer) (Rev 4/9/14) 1 Employer has not furnished me with form(s) 1 W 2 form 3 W 2C form 2 Form(s) given to me by employer is/are incorrect 2 W 2P form 4 1099 form 3 Form(s) is/are lost 3236 SUBSTITUTE FOR FORM W 2 32361024 4 Form(s) given to me by employer is/are illegible Address State Amount of wages Attach copies of pay stubs military leave and earnings statement or other documentation to support your claim check Check applicable box: DEPARTMENT OF REVENUE SC4852 Employer's address city state and zip code Employer's Identification number (if known) Employer's name Employer's telephone number Estimated South Carolina income taxes withheld Explain how you calculated the amount of wages received and the amount of estimated South Carolina income taxes withheld Explain the efforts made to obtain an accurate form W 2 W 2P W 2C 1099: File This Form With Your South Carolina Tax Return for identification purposes fraudulent statement to the Department is a crime Has your present address been furnished I declare that this return and all attachments are true correct and complete to the best of my knowledge and belief To wilfully furnish a false or It is mandatory that you provide your social security number on this tax form 42 U S C 405(c)(2)(C)(i) permits a state to use an individual's social Period worked for this employer Please mark the form you are referencing: REQUIRED INFORMATION security number as means of identification in administration of any tax SC Regulation 117 201 mandates that any person required to make a return to Signature Social Security Privacy Act STATE OF SOUTH CAROLINA Tax year the SC Department of Revenue shall provide identifying numbers as prescribed for securing proper identification Your social security number is used to the employer? Type of business WAGE AND TAX STATEMENT Wages Paid in: Yes No Your full name (Type or print) Social Security Number Your telephone number Zip Code