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 2005

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 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 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 records16 through 25.

Date tips received	Date of entry	a. Tips received directly from customers and other employees	b. Credit 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 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