Form  
4137 
Department of the Treasury  
Internal Revenue Service (99)
Social Security and Medicare Tax 
on Unreported Tip Income
a
.
a
 Attach to Form 1040, Form 1040NR, Form 1040NR-EZ, Form 1040-SS, or Form 1040-PR.
OMB No. 1545-0074
20
13
Attachment   
Sequence No. 
24
Name of person who received tips. If married, complete a separate Form 4137 for each spouse with unreported tips. 
Social security number 
1 
(a)  
Name of employer to whom
 
 
 
you were required to, but did not 
report all your tips (see instructions) 
(b)  
Employer
 
 
identification number
 
(see instructions) 
(c)  
Total cash and charge 
 
tips you received (including  
unreported tips) (see instructions) 
(d)  
Total cash and charge 
  
tips you reported to your  
employer 
 
 
  
   
   
   
   
   
   
A 
B 
C 
D 
E 
2 
 
Total cash and charge tips you 
received 
in 2013. Add the 
amounts from line 1, column (c)
...........
2 
3 
 
Total cash and charge tips you 
reported 
to your employer(s) in 2013. Add the amounts from
line 1, column (d)
..........................
3
4 
 
Subtract line 3 from line 2. This amount is income you 
must 
include in the total on Form 1040, 
line 7; Form 1040NR, line 8; or Form 1040NR-EZ, line 3
.............
4
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)
...............
5
6 
Unreported tips subject to Medicare tax. Subtract line 5 from line 4
.........
6 
7 
 
Maximum amount of wages (including tips) subject to 
social security tax
................
7 
8 
 
 
 
Total social security wages and social security tips (total of boxes 
3 and 7 shown on your Form(s) W-2) and railroad retirement 
(RRTA)  compensation (subject to 6.2 percent rate), see 
instructions
..................
8
9 
Subtract line 8 from line 7. If line 8 is more than line 7, enter -0- 
..........
9
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
.....
10
11 
Multiply line 10 by .062 (social security tax rate)
................ 
11 
12 
Multiply line 6 by .0145 (Medicare tax rate)
..................
12 
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.)
.....
13 
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 12626C 
Form 
4137
 (2013) 
113,700     00 
 Information about Form 4137 and its instructions is at www.irs.gov/form4137
----------------Page (0) Break----------------