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 and debit 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, 2011, to October 31, 2011

Signature field contains John W. Allen

Date field contains November 10, 2011