Get forms and other information faster and easier at: • IRS.gov (English) • IRS.gov/Spanish (Español) • IRS.gov/Chinese (中文) Dec 12, 2016 • IRS.gov/Korean (한국어) • IRS.gov/Russian (Pусский) • IRS.gov/Vietnamese (TiếngViệt) An employer is required to withhold Additional Medicare Tax on any Medicare wages or RRTA compensation it pays to an employee in excess of 200,000 in a calendar year without regard to the employee s filing status.. Credit and debit card tips received 18.40 21.20 12.80 19.20 8.80 9.60 8.40 10.00 Judy Brown Judy Brown Carl Jones Judy Brown 26.00 22.80 17.20 19.20 14.80 171.60 12.80 12.40 13.60 10.80 9.20 95.60 Judy Brown Brian Smith Carl Jones Judy Brown Brian Smith Judy Brown Page 3 Date tips rec’d Date of entry 26 10/26 27 10/27 28 10/29 29 10/30 30 10/31 31 11/2 Subtotals from pages 1, 2, and 3 Totals a.. Reporting Tips to Your Employer Why report tips to your employer You must report tips to your employer so that: Your employer can withhold federal income tax and social security, Medicare, Additional Medicare , or railroad retirement taxes Your employer can report the correct amount of your earnings to the Social Security Administration or Railroad Retirement Board (which affects your benefits when you retire or if you become disabled, or your family s benefits if you die) and You can avoid the penalty for not reporting tips to your employer (explained later).. 1545-0074 Social security number 987 00 4321 1 Cash tips received Employer’s name and address (include establishment name, if different) 1,024.00 Diamond Restaurant 834 Main Street Anytown, NY 14203 2 Credit and debit card tips received 519.20 3 Tips paid out 273.60 4 Net tips (lines 1 + 2 - 3) Month or shorter period in which tips were received from October 1 Signature signed , 2016 , to October 31 John W.. A Additional Medicare Tax 1 Allocated tips 6 Assistance (See Tax help) C Cash tips 2 Credit card charge tips 2 D Daily tip record 2 E Electronic tip record 3 Electronic tip statement
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