Sample Filled-in Form 4070A from Publication 1244

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

Employee's name and address” field contains
John W. Allen
1117 Maple Ave.
Anytown, NY 14202
Employer's name” field contains Diamond Restaurant
Month and year” field contains October 2014

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