Form 4137 - Social Security And Medicare Tax On Unreported Tip Income - 2012
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44137
Social Security and Medicare Tax
OMB No. 1545-0074
on Unreported Tip Income
2012
Form
Information about Form 4137 and its instructions is at
Department of the Treasury
▶
Attachment
Internal Revenue Service (99)
24
Attach to Form 1040, Form 1040NR, Form 1040NR-EZ, Form 1040-SS, or Form 1040-PR.
Sequence No.
▶
Name of person who received tips. If married, complete a separate Form 4137 for each spouse with unreported tips.
Social security number
(a) Name of employer to whom
(b) Employer
(c) Total cash and charge
(d) Total cash and charge
1
you were required to, but did not
identification number
tips you received (including
tips you reported to your
report all your tips (see instructions)
(see instructions)
unreported tips) (see instructions)
employer
A
B
C
D
E
2 Total cash and charge tips you received in 2012. Add the
amounts from line 1, column (c) .
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3 Total cash and charge tips you reported to your employer(s) in 2012. Add the amounts from
line 1, column (d) .
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4 Subtract line 3 from line 2. This amount is income you must include in the total on Form 1040,
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line 7; Form 1040NR, line 8; or Form 1040NR-EZ, line 3 .
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5 Cash and charge tips you received but did not report to your employer because the total was
less than $20 in a calendar month (see instructions).
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6 Unreported tips subject to Medicare tax. Subtract line 5 from line 4
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7 Maximum amount of wages (including tips) subject to
social security tax .
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110,100 00
8 Total social security wages and social security tips (total of boxes
3 and 7 shown on your Form(s) W-2) or railroad retirement (tier 1)
compensation .
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9 Subtract line 8 from line 7. If line 8 is more than line 7, enter -0-
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10 Unreported tips subject to social security tax. Enter the smaller of line 6 or line 9. If you
received tips as a federal, state, or local government employee, see instructions .
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11 Multiply line 10 by .042 (social security tax rate) .
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12 Multiply line 6 by .0145 (Medicare tax rate).
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13 Add lines 11 and 12. Enter the result here and on Form 1040, line 57; Form 1040NR, line 55; or
Form 1040NR-EZ, line 16 (Form 1040-SS and 1040-PR filers, see instructions.)
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4137
For Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2012)
Cat. No. 12626C
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