Hawaii Resale Certificate Special Form

Resale Certificate Special Form
Form G-19, Rev. 2016,  Resale Certificate Special Form
Clear Form
FORM G-19
(REV. 2016)

STATE OF HAWAII — DEPARTMENT OF TAXATION

RESALE CERTIFICATE
SPECIAL FORM
(For use singly or with General Form 2)

To
		

Name of Seller

		

	

Address of Seller			

City	

State	

Date of this Certificate

Postal/ZIP Code

The undersigned hereby certifies the following under penalties set forth in section 231-36, Hawaii Revised Statutes
(HRS), as Purchaser or as an authorized agent or representative of the named Purchaser, pursuant to section 237-13(2)(F),
HRS, and Hawaii Administrative Rules (HAR), relating to resale certificates and sales at wholesale:
That the Purchaser is the holder of Hawaii Tax Identification No. GE __ __ __ -__ __ __ -__ __ __ __ - __ __ under the
General Excise Tax Law and subject to the taxing jurisdiction of the State.
That the Purchaser is engaged in the contracting business or is subject to taxation the same as if so engaged.
That until this Certificate is revoked by notice in writing, it shall apply to all sales of materials or commodities which the
Purchaser shall purchase from the Seller named above in connection with that certain work or project identified below, except
those orders as to which the Purchaser shall specify by notice in writing that this Certificate does not apply. The work or project is:
Brief description

Location, described by street address

Tax Map Key Number	

Building Permit Number

That all the materials and commodities to which this Certificate applies will be incorporated into the finished work or
project identified above and will remain in such finished work or project in such form as to be perceptible to the senses.
That the work or project identified above is one in which the Purchaser is engaged as a part of his or her contracting
business, or one which renders the Purchaser liable to the same tax as if engaged in the business of contracting, as set forth
in section 237-4(a)(4), HRS, and section 18-237-4(a)(4), HAR, and that it is not a federal cost-plus contract governed by the
election provided for by section 237-13(3)(C), HRS.
That the Purchaser, pursuant to section 237-13(2)(F)(i), HRS and section 18-237-13-02(d)(2)(B), HAR, shall pay to the
seller the amount of any additional tax imposed upon the seller with respect to any transactions covered by this certificate.

	

Name of Purchaser			

Signature

	

Address of Purchaser			

Print Name of Signatory

	 City	

State	

Postal/ZIP Code	

Title (Owner, Partner or Member, Officer, or Duly Authorized Agent)		
Date

Seller should retain this Certificate for Seller’s files. Do NOT send to the Department of Taxation.
FORM G-19