Sample Filled-in Form 4070A from Publication 1244 Sample Filled-in Form 4070A from Publication 1244 The graphic shows a sample filled-in Form 4070-A. "Employee's name and address" field contains John W. Allen1117 Maple Ave.Anytown, NY 14202 "Employer's name" field contains Diamond Restaurant "Month and year" field contains October 2020 The following is a description of records 1 through 5.Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips110/3Off 210/348.8026.4015.20Judy Brown310/328.0021.608.00Carl Jones410/542.0024.0010.00Judy Brown510/740.8028.0012.00Judy Brown and Brian SmithSubtotalsblank159.60100.0045.20blankThe following is a description of records 6 through 15.Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips610/7Off 710/837.2022.408.00Carl Jones810/950.8017.2010.00Judy Brown and Carl Jones910/933.6016.408.00Judy Brown1010/1130.4022.009.20Judy Brown1110/1142.0011.608.80Carl Jones1210/1435.6016.007.60Judy Brown1310/14Off 1410/1448.4014.4012.40Judy Brown and Brian Smith1510/1645.2032.0017.20Brian SmithSubtotalsblank323.20152.0081.20blankThe following is a description of records 16 through 25.Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips1610/1641.2018.408.80Judy Brown1710/1839.2021.209.60Judy Brown1810/1946.8012.808.40Carl Jones1910/2134.0019.2010.00Judy Brown2010/21Off 2110/2234.8026.0012.80Judy Brown and Brian Smith2210/2442.4022.8012.40Carl Jones2310/2448.8017.2013.60Judy Brown2410/2533.6019.2010.80Brian Smith2510/2637.2014.809.20Judy BrownSubtotalsblank358.00171.6095.60blankThe following is a description of records 26 through 31 and the total tips for the month of October.Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips2610/2631.6011.6012.40Judy Brown2710/27Off 2810/2943.2014.0012.80Carl Jones2910/3034.8022.407.20Carl Jones3010/3146.0027.2012.80Judy Brown and Brian Smith3111/227.6020.406.40Judy BrownSubtotals from pages 1, 2, and 3blank(page 1) 159.60, (page 2) 323.20, (page 3) 358.00(page 1) 100.00, (page 2) 152.00, (page 3) 171.60(page 1) 45.20, (page 2) 81.20, (page 3) 95.60blankTotalsblank1,024.00519.20273.60blank