Sample Filled-in Form 4070 from Publication 1244. The graphic shows the a sample filled-in Form 4070.
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“Employee's name and address” field contains
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John W. Allen
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1117 Maple Ave.
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Anytown, NY 14202
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“Social security number” field contains 987 00 4321
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“Employer's name and address (include establishment name, if different)” field contains
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Diamond Restaurant
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834 Main Street
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Anytown, NY 14203
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“ 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, 2004
“ , to” October 31, 2004
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“Signature” field contains John W. Allen
“Date” field contains November 6, 2004
