This form contains 42 fields organized into 7 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Contact Information
Title Text
Enter the title of the person completing this form (e.g., Manager, Owner).
Employee Information
topmostSubform[0].Page1[0].f1_28[0 Text
Enter the total number of employees who received tips using a 3-digit code.
Max length: 3 characters
8 Enter the total number of directly tipped employees at this establishment during 2023 Text
Enter the total number of employees who received tips directly from customers at this establishment during the year 2023.
Employer Information
Employer's name (see instructions) Text
Enter the employer's name as instructed.
Number and street (or P.O. box number, if mail isn't delivered to street address) Text
Enter the number and street address (or P.O. box number if mail isn't delivered to the street address) of the employer.
Apt. or suite no Text
Enter the apartment or suite number of the employer's address.
Establishment Information
topmostSubform[0].Page1[0].CheckIf[0].c1_1[0]_1 CheckBox
Check this box if the establishment is a large food or beverage establishment.
topmostSubform[0].Page1[0].CheckIf[0].c1_1[1]_2 CheckBox
Check this box if the establishment is a gaming establishment.
Name of establishment Text
Enter the name of the establishment.
Number and street (don't enter a P.O. box). See instructions Text
Enter the number and street address of the establishment. Do not enter a P.O. box.
City or town, state, and ZIP code Text
Enter the city or town, state, and ZIP code of the establishment.
topmostSubform[0].Page1[0].f1_4[0 Text
Enter the Employer Identification Number (EIN) of the establishment. This should be a 10-digit number.
Max length: 10 characters
topmostSubform[0].Page1[0].c1_2[0]_1 CheckBox
Check this box if the establishment is a large food or beverage establishment.
topmostSubform[0].Page1[0].c1_2[1]_2 CheckBox
Check this box if the establishment is a gaming establishment.
topmostSubform[0].Page1[0].c1_2[2]_3 CheckBox
Check this box if the establishment is a large food or beverage establishment.
topmostSubform[0].Page1[0].c1_2[3]_4 CheckBox
Check this box if the establishment is a gaming establishment.
topmostSubform[0].Page1[0].NameAddress_ReadOrder[0].f1_8[0 Text
Enter the name and address of the establishment.
topmostSubform[0].Page1[0].EstablishmentNoComb[0].f1_9[0 Text
Enter the establishment number. This should be a 5-digit number.
Max length: 5 characters
topmostSubform[0].Page1[0].f1_10[0 Text
Enter the employer identification number (EIN) of the establishment.
topmostSubform[0].Page1[0].f1_11[0 Text
Enter the type of establishment. This should be a 3-character code.
Max length: 3 characters
topmostSubform[0].Page1[0].f1_20[0 Text
Enter the name of the establishment.
topmostSubform[0].Page1[0].f1_21[0 Text
Enter the type of establishment using a 3-digit code.
Max length: 3 characters
topmostSubform[0].Page1[0].f1_22[0 Text
Enter the address of the establishment.
topmostSubform[0].Page1[0].f1_23[0 Text
Enter the employer identification number (EIN) of the establishment using a 3-digit code.
Max length: 3 characters
topmostSubform[0].Page1[0].c1_4[0]_1 CheckBox
Check this box if the establishment is a large food or beverage establishment.
topmostSubform[0].Page1[0].c1_4[1]_2 CheckBox
Check this box if the establishment is a gaming establishment.
topmostSubform[0].Page1[0].c1_4[2]_3 CheckBox
Check this box if the establishment is a non-gaming establishment.
Establishment Type
topmostSubform[0].Page1[0].c1_3[0]_1 CheckBox
Check this box if the establishment is a large food or beverage establishment.
topmostSubform[0].Page1[0].c1_3[1]_2 CheckBox
Check this box if the establishment is a gaming establishment.
Financial Information
2 Total charge receipts showing charged tips (see instructions). 2 Text
Enter the total charge receipts showing charged tips.
1013 Text
Enter the total charge receipts showing charged tips. This should be a 3-digit number.
Max length: 3 characters
topmostSubform[0].Page1[0].f1_14[0 Text
Enter the total amount of service charges.
topmostSubform[0].Page1[0].f1_15[0 Text
Enter the total amount of service charges. This should be a 3-digit number.
Max length: 3 characters
4a Total tips reported by indirectly tipped employees 4a Text
Enter the total tips reported by indirectly tipped employees.
0858 Text
Enter the total tips reported by indirectly tipped employees. This should be a 3-digit number.
Max length: 3 characters
topmostSubform[0].Page1[0].f1_18[0 Text
Enter the total amount of allocated tips.
4bb77a Text
Enter the total amount of allocated tips. This should be a 3-digit number.
Max length: 3 characters
topmostSubform[0].Page1[0].f1_29[0 Text
Enter the total gross receipts from food and beverage operations.
Tip Information
topmostSubform[0].Page1[0].Line6_ReadOrder[0].f1_24[0 Text
Enter the total charged tips for the year.
topmostSubform[0].Page1[0].f1_25[0 Text
Enter the total amount of service charges for the year.
topmostSubform[0].Page1[0].f1_26[0 Text
Enter the total allocated tips for the year using a 3-digit code.
Max length: 3 characters
topmostSubform[0].Page1[0].f1_27[0 Text
Enter the total tips reported by employees for the year.