Transcription of Internal Revenue Service Month and year Establishment name ...
1 4070 AForm(Rev. August 2005)OMB No. 1545-007412345 Employee s Daily Record of TipsThis is a voluntary form provided for your instructions for records you must and yearEmployer s nameEmployee s name and addressEstablishment name (if different)For Paperwork Reduction Act Notice, see Instructions on the back of Form Tips receiveddirectly from customersand other and debitcard tips receivedc. Tips paid out toother employeesd. Names of employees to whom youpaid tipsDateofentrySubtotalsPage 1 Datetipsrec dDepartment of the TreasuryInternal Revenue Service6789101112131415a. Tips receiveddirectly from customersand other and debitcard tips receivedc.
2 Tips paid out toother employeesd. Names of employees to whom youpaid tipsDateofentrySubtotalsPage 2 Datetipsrec d16171819202122232425a. Tips receiveddirectly from customersand other and debitcard tips receivedc. Tips paid out toother employeesd. Names of employees to whom youpaid tipsDateofentrySubtotalsPage 3 Datetipsrec dSubtotalsfrom pages1, 2, and total cash tips (col. a) on Form 4070 , line Tips receiveddirectly from customersand other and debitcard tips receivedc. Tips paid out toother employeesd. Names of employees to whom youpaid tipsDateofentryPage 4 Datetipsrec total credit and debit card tips (col.)
3 B) on Form 4070 , line total tips paid out (col. c) on Form 4070 , line 3.
