His must also have code JP. The J is necessary to indicate that the return of contribution was from a Roth IRA. His penalty can be eliminated by claiming an Other Reason exception to the early-distribution penalty on the amount of the earnings.
Since the real Forms 1099-R are not late, I would not be entering this as a substitute Form 1099-R. The explanation statement that you must prepare for the return of contribution will suffice to explain the taxable earnings appearing on Form 1040 line 15b or Form 1040A line 11b. Entering it as a Form 4852 will preclude you from e-filing.
