Clear Form
FORM M-104
STATE OF HAWAII — DEPARTMENT OF TAXATION
(Rev. 2008)
EXPORT EXEMPTION CERTIFICATE
FOR CIGARETTE AND TOBACCO TAXES
PART I
Information About the Cigarette Tax
PART II Information About the Purchaser,
and Tobacco Tax Licensee
Consumer, or User
Name
Name
Type of organization (e.g., Corporation, Partnership, Individual, etc.)
Type of organization (e.g., Corporation, Partnership, Individual, etc.)
Address
Address
City
State
Zip Code
City
State
Zip Code
Hawaii Tax I.D. Number: W __ __ __ __ __ __ __ __ - __ __
Cigarette Tax and Tobacco
Tax License Number:
PART III Cigarettes or Tobacco Products Included in Transaction
A.
Description of cigarettes or tobacco products
B.
Value of cigarettes or tobacco products or gross proceeds involved
C.
Number of cigarettes involved
CERTIFICATION BY CIGARETTE TAX AND TOBACCO TAX LICENSEE; AND
PURCHASER, CONSUMER, OR USER
The undersigned cigarette tax and tobacco tax licensee; and purchaser, consumer, or user hereby certify, pursuant to sections 231-36 and 245-32, Hawaii
Revised Statutes (HRS), as amended, and section 18-245-6, Hawaii Administrative Rules, relating to export exemption and certification:
(1) that the information provided in Parts I, II, and III above are true and correct;
(2) that until this certificate is revoked by notice in writing by either of the parties who signed the certificate or the Department of Taxation, it shall apply to
this order or contract of sale between the cigarette tax and tobacco tax licensee; and the purchaser, consumer, or user; and
(3) that for the sale of cigarettes, the cigarette tax stamps were placed upon the cigarette packages.
The cigarette tax and tobacco tax licensee certifies that he/she will remit the tax due on the sale of the tobacco products, or will not request a refund of
the cigarette tax paid with cigarette tax stamps, as imposed by Chapter 245, HRS, to the Department of Taxation if:
(1) the place of delivery of the cigarettes or tobacco products for which the export exemption was claimed is not outside the State;
(2) the cigarettes or tobacco products were not shipped or transmitted by the cigarette tax and tobacco tax licensee to the purchaser at a place of delivery
outside the State; or
(3) the cigarettes or tobacco products were not resold, consumed, or used outside the State.
Cigarette Tax and Tobacco Tax Licensee signature
Purchaser, consumer, or user signature
Print name of signatory
Title
Date
Print name of signatory
Title
Date
FORM M-104