This is archived information that pertains only to the 2006 Tax Year. If you
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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, 2006 “, to” October 31, 2006

“Signature” field contains John W. Allen “Date” field contains November 7, 2006