Sample Filled-in Form 4070A from Publication 1244

The graphic shows a sample filled-in Form 4070A.
The following is a description of records 1 through 5.
Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips
110/3Off   
210/348.8026.4015.20Judy Brown
310/328.0021.608.00Carl Jones
410/542.0024.0010.00Judy Brown
510/740.8028.0012.00Judy Brown and Brian Smith
Subtotalsblank159.60100.0045.20blank
The following is a description of records 6 through 15.
Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips
610/7Off   
710/837.2022.408.00Carl Jones
810/950.8017.2010.00Judy Brown and Carl Jones
910/933.6016.408.00Judy Brown
1010/1130.4022.009.20Judy Brown
1110/1142.0011.608.80Carl Jones
1210/1435.6016.007.60Judy Brown
1310/14Off   
1410/1448.4014.4012.40Judy Brown and Brian Smith
1510/1645.2032.0017.20Brian Smith
Subtotalsblank323.20152.0081.20blank
The following is a description of records16 through 25.
Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips
1610/1641.2018.408.80Judy Brown
1710/1839.2021.209.60Judy Brown
1810/1946.8012.808.40Carl Jones
1910/2134.0019.2010.00Judy Brown
2010/21Off   
2110/2234.8026.0012.80Judy Brown and Brian Smith
2210/2442.4022.8012.40Carl Jones
2310/2448.8017.2013.60Judy Brown
2410/2533.6019.2010.80Brian Smith
2510/2637.2014.809.20Judy Brown
Subtotalsblank358.00171.6095.60blank
The following is a description of records 26 through 31 and the total tips for the month of October.
Date tips receivedDate of entrya. Tips received directly from customers and other employeesb. Credit and debit card tips receivedc. Tips paid out to other employeesd. Names of employees to whom you paid tips
2610/2631.6011.6012.40Judy Brown
2710/27Off   
2810/2943.2014.0012.80Carl Jones
2910/3034.8022.407.20Carl Jones
3010/3146.0027.2012.80Judy Brown and Brian Smith
3111/227.6020.406.40Judy Brown
Subtotals from pages 1, 2, and 3blank(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) 95.60blank
Totalsblank1,024.00519.20273.60blank

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