Yes, if you cannot get a corrected Form 1099-R then you would have to file a substitute Form 1099-R and include Form 4852.
Yes, you would put the distribution amount of $1,433.59 in box 1, the earnings of $58.59 in box 2a, and $1,375 in box 5.
Another option is to file an extension if your are waiting if they will fix the Form 1099-R. Please see How do I file an IRS tax extension?
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