Form X-4 - Application For Reinstatement - 2004
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1FORM X-4
B
R
WWW.
USINESS
3/2004
Nonrefundable Filing Fee:
STATE OF HAWAII
Profit Corporation: $50.00
*X4*
Nonprofit Corporation: $20.00
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
General Partnership: $25.00
Business Registration Division
Limited Partnership: $20.00
LLC: $50.00
335 Merchant Street
LLP: $50.00
Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810
Clear Form
APPLICATION FOR REINSTATEMENT
(Section 414-403, 415A-18, 414D-250, 425-14, 425-164, 425D-203.6, 428-811, Hawaii Revised Statutes)
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK
The undersigned, submitting this application for reinstatement, certify as follows:
1. The entity is (check one):
Profit Corporation
Nonprofit Corporation
General Partnership
Limited Partnership
LLC
LLP
(F/$50/B15)
(F/$20/B15)
(F/$25/B29, SH/12)
(F/$20/B31)
(F/$50/L14)
(F/$50/L34)
2. Name of business entity:
______________________________________________________________________________________________________________
(Corporation, Partnership, LLC Name)
3. The business entity was involuntarily dissolved/canceled/revoked or administratively terminated by Decree/Order issued by
the Director of Commerce and Consumer Affairs on:
_____________________________________________________________ .
(Month
Day
Year)
4 Attached are the delinquent annual statements/reports for the years ended December 31, ________________,
________________, ________________, ________________, ________________,
________________ .
5. Attached is a Tax Clearance from the Department of Taxation, State of Hawaii.
6. By this filing, all delinquent fees, penalties and other costs have been paid.
7. Attached is payment for all filing fees, penalties and other costs in the amount of $ ____________________________ .
We certify under the penalties of Section 414-20, 414D-12, 425-13, 425D-204, 425D-1108, 428-1302, and 425-172, Hawaii
Revised Statutes, as applicable, that we have read the above statements and that the same are true and correct.
Signed this ____________day of ___________________________________, __________
_______________________________________________________
________________________________________________________
(Type/Print Name & Title)
(Type/Print Name & Title)
_______________________________________________________
________________________________________________________
(Signature)
(Signature)
SEE INSTRUCTIONS ON REVERSE SIDE
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