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
  1. Cash tips received field contains 1,024.00
  2. Credit card tips received field contains 519.20
  3. Tips paid out field contains 273.60
  4. Net tips (lines 1+2-3) field contains 1,269.60
  5. Month or shorter period in which tips were received field contains from October 1, 2008 , to October 31, 2008

Signature field contains John W. Allen

Date field contains November 7, 2008