Sample Filled-in Form 4070A from Publication 1244
Sample Filled-in Form 4070A from Publication 1244
The graphic shows a sample filled-in Form 4070A.
| "Employee's name and address" field contains | |||
| |||
| "Employer's name" field contains Diamond Restaurant | |||
| "Month and year" field contains October 2017 |
The following is a description of records 1 through 5.
| Date tips received | Date of entry | a. Tips received directly from customers and other employees | b. Credit and debit card tips received | c. Tips paid out to other employees | d. Names of employees to whom you paid tips |
|---|---|---|---|---|---|
| 1 | 10/3 | Off | |||
| 2 | 10/3 | 48.80 | 26.40 | 15.20 | Judy Brown |
| 3 | 10/3 | 28.00 | 21.60 | 8.00 | Carl Jones |
| 4 | 10/5 | 42.00 | 24.00 | 10.00 | Judy Brown |
| 5 | 10/7 | 40.80 | 28.00 | 12.00 | Judy Brown and Brian Smith |
| Subtotals | blank | 159.60 | 100.00 | 45.20 | blank |
The following is a description of records 6 through 15.
| Date tips received | Date of entry | a. Tips received directly from customers and other employees | b. Credit and debit card tips received | c. Tips paid out to other employees | d. Names of employees to whom you paid tips |
|---|---|---|---|---|---|
| 6 | 10/7 | Off | |||
| 7 | 10/8 | 37.20 | 22.40 | 8.00 | Carl Jones |
| 8 | 10/9 | 50.80 | 17.20 | 10.00 | Judy Brown and Carl Jones |
| 9 | 10/9 | 33.60 | 16.40 | 8.00 | Judy Brown |
| 10 | 10/11 | 30.40 | 22.00 | 9.20 | Judy Brown |
| 11 | 10/11 | 42.00 | 11.60 | 8.80 | Carl Jones |
| 12 | 10/14 | 35.60 | 16.00 | 7.60 | Judy Brown |
| 13 | 10/14 | Off | |||
| 14 | 10/14 | 48.40 | 14.40 | 12.40 | Judy Brown and Brian Smith |
| 15 | 10/16 | 45.20 | 32.00 | 17.20 | Brian Smith |
| Subtotals | blank | 323.20 | 152.00 | 81.20 | blank |
The following is a description of records 16 through 25.
| Date tips received | Date of entry | a. Tips received directly from customers and other employees | b. Credit and debit card tips received | c. Tips paid out to other employees | d. Names of employees to whom you paid tips |
|---|---|---|---|---|---|
| 16 | 10/16 | 41.20 | 18.40 | 8.80 | Judy Brown |
| 17 | 10/18 | 39.20 | 21.20 | 9.60 | Judy Brown |
| 18 | 10/19 | 46.80 | 12.80 | 8.40 | Carl Jones |
| 19 | 10/21 | 34.00 | 19.20 | 10.00 | Judy Brown |
| 20 | 10/21 | Off | |||
| 21 | 10/22 | 34.80 | 26.00 | 12.80 | Judy Brown and Brian Smith |
| 22 | 10/24 | 42.40 | 22.80 | 12.40 | Carl Jones |
| 23 | 10/24 | 48.80 | 17.20 | 13.60 | Judy Brown |
| 24 | 10/25 | 33.60 | 19.20 | 10.80 | Brian Smith |
| 25 | 10/26 | 37.20 | 14.80 | 9.20 | Judy Brown |
| Subtotals | blank | 358.00 | 171.60 | 95.60 | blank |
The following is a description of records 26 through 31 and the total tips for the month of October.
| Date tips received | Date of entry | a. Tips received directly from customers and other employees | b. Credit and debit card tips received | c. Tips paid out to other employees | d. Names of employees to whom you paid tips |
|---|---|---|---|---|---|
| 26 | 10/26 | 31.60 | 11.60 | 12.40 | Judy Brown |
| 27 | 10/27 | Off | |||
| 28 | 10/29 | 43.20 | 14.00 | 12.80 | Carl Jones |
| 29 | 10/30 | 34.80 | 22.40 | 7.20 | Carl Jones |
| 30 | 10/31 | 46.00 | 27.20 | 12.80 | Judy Brown and Brian Smith |
| 31 | 11/2 | 27.60 | 20.40 | 6.40 | Judy Brown |
| Subtotals from pages 1, 2, and 3 | blank | (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) 95.60 | blank |
| Totals | blank | 1,024.00 | 519.20 | 273.60 | blank |