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Click ‘Get Form’ to open it in the editor.
Begin by entering your first name, middle initial, and last name in the designated fields.
Input your Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) accurately.
Fill in your complete address, including street number, apartment or suite number, city, state, and ZIP code.
In the provided space, enter the year for which you are submitting this statement regarding your inability to obtain Form W-2 or Form 1099-R.
Complete the employer’s or payer’s information including their name and address.
Indicate any state income tax withheld and provide details about wages, tips, and other compensation as required in sections 8 through 15.
Explain how you estimated the amounts in items 7–15 and provide reasons for not receiving the necessary forms from your employer or payer.
Finally, sign and date the form under penalties of perjury to confirm that all information is true and complete.

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