Exhibit 3.11.180-1 provides a sample of the Form 8027, Employer's Annual Information Return of Tip Income and Allocated Tips. The location of each transcription (T) line is identified by a two-digit element number. A table containing the element number, the item description and the location on the Form 8027 follows this exhibit.Top left corner of Form 8027 reads: DRAFTT 01 - Center top area of Form 8027 - Block DLNT 02 - Center top area of Form 8027 - Serial Number of DLNT 24 - Right upper area of Form 8027 - Tax YearT 25 - Left of the check boxes for Amended Return and Final Return (as close to that area as possible) - Special Return CodeT 04 - Establishment area - Name of EstablishmentT 09 - Right upper area of Form 8027 - Employer Identification Number - EINT 27 - Establishment area - Number and Street of EstablishmentT 05 - Establishment area - City of EstablishmentT 06 - Establishment area - State of EstablishmentT 07 - Establishment area - ZIP Code of EstablishmentT 10 - Right upper area of Form 8027 - Establishment Type CodeT 08 - Employer area - Employer’s NameT 28 - Employer area - Number and Street of EmployerT 11 - Right of Employer area - Establishment NumberT 29 - Employer area - City of EmployerT 30 - Employer area - Street of EmployerT 31 - Employer area - ZIP Code of EmployerT 03 - Dotted area of Line 1 - Amended Document CodeT 12 - Line 1 - Total Charged Tips for Calendar YearT 13 - Line 2 - Total Charge Receipts Showing Charged TipsT 14 - Line 3 - Total Amount of Service Charges of Less than 10% Paid as Wages to EmployeesT 26 - Center area of Form 8027 - MMDDYY - Received DateT 15 - Line 4a - Total Tips Reported by Indirectly Tipped EmployeesT 16 - Line 4b - Total Tips Reported by Directly Tipped EmployeesT 17 - Line 4c - Total Tips Reported (Add lines 4a and 4b)T 18 - Line 5 - Gross Receipts from food and beveragesT 20 - Line 6 (Center area) - Lower rate show here lineT 19 - Line 6 - Multiple line 5 by 8%T 21 - Line 7 - Allocation of tipsT 22 - Line 7a, Line 7b, Line 7c - Allocation MethodT 23 - Line 8 - Enter the Total Number of directly tipped employees at this establishmentSignature line - Text box reads: Correspond if signature is missing