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
|
“ Cash tips received” field contains 1,024.00
“ Credit card tips received” field contains 519.20
“ Tips paid out” field contains 273.60
“ Net tips (lines 1+2-3)” field contains 1,269.60
“ Month or shorter period in which tips were received” field contains
“ from” October 1, 2007
“ , to” October 31, 2007
|
“Signature” field contains John W. Allen
“Date” field contains November 7, 2007
