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 and debit 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, 2014“, to” October 31, 2014

Signature” field contains John W. Allen

Date” field contains November 11, 2014