Form N-4 - Statement Of Withholding For A Nonresident Shareholder Of An S Corporation Page 2

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DO NOT WRITE OR STAPLE IN THIS SPACE
Form
N-4
STATE OF HAWAII — DEPARTMENT OF TAXATION
STATEMENT OF WITHHOLDING
(Rev. 2006)
20
FOR A NONRESIDENT SHAREHOLDER
OF AN S CORPORATION
Ÿ
S Corporation’s Tax Year Ending
,
20
Copy B - For Your Records
Ÿ
1. S Corporation’s Name and Mailing Address
2. Shareholder’s SSN or FEIN
Ÿ
3. Amount of Hawaii Tax Withheld
•
4. S Corporation’s FEIN
5. Shareholder’s Name and Mailing Address
6. Shareholder’s Share of S Corporation’s
Hawaii Income
Form N-4
DO NOT WRITE OR STAPLE IN THIS SPACE
Form
N-4
STATE OF HAWAII — DEPARTMENT OF TAXATION
STATEMENT OF WITHHOLDING
(Rev. 2006)
20
FOR A NONRESIDENT SHAREHOLDER
OF AN S CORPORATION
Ÿ
S Corporation’s Tax Year Ending
,
20
Copy B - For Your Records
Ÿ
1. S Corporation’s Name and Mailing Address
2. Shareholder’s SSN or FEIN
Ÿ
3. Amount of Hawaii Tax Withheld
•
4. S Corporation’s FEIN
5. Shareholder’s Name and Mailing Address
6. Shareholder’s Share of S Corporation’s
Hawaii Income
Form N-4

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