Sample Filled-in Form 4070 from Publication 1244

The graphic shows the a sample filled-in Form 4070.

  • Employee's name and address field contains
  • John W. Allen
  • 1117 Maple Ave.
  • Anytown, NY 14202
  • Social security number field contains 987 00 4321
  • Employer's name and address (include establishment name, if different) field contains
  • Diamond Restaurant
  • 834 Main Street
  • Anytown, NY 14203
    1. Cash tips received field contains 1,024.00
    2. Credit card tips received field contains 519.20
    3. Tips paid out field contains 273.60
    4. Net tips (lines 1+2-3) field contains 1,269.60
    5. Month or shorter period in which tips were received field contains from October 1, 2007 , to October 31, 2007

    • Signature field contains John W. Allen

    Date field contains November 7, 2007

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