Western Omelette 2 Tip Claim

Today's Date*

From (Beginning of work week)*

To (End of work week)*

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

First 3 of Social Security Number*

Second 2 of Social Security Number*

Last 4 of Social Security Number*

Hidden

Employer's Name and Address*

Please enter your employer’s business name and their complete address.

Cash Tips Received*

These are tips you received from the customer directly. (Cash)

Credit and Debit Card Tips Received*

These are tips that were entered on credit or debit card receipts.

Tips Paid Out*

These are tips that you paid to another staff member. (Busser or Bartender)

Net Tips 1 + 2 – 3

This Field Is Automatically Populated

Signature

Email

This field is for validation purposes and should be left unchanged.

Western Omelette 2 Tip Claim Form 4070