Hawaii Application to Purchase Cigarette Tax Stamps

Application to Purchase Cigarette Tax Stamps
Form M-100A, Rev. 2022, Application to Purchase Cigarette Tax Stamps
Clear Form

FORM M-100A
(REV. 2022)

STATE OF HAWAII — DEPARTMENT OF TAXATION

APPLICATION TO PURCHASE CIGARETTE TAX STAMPS
M100A_I 2022A 01 VID01

    Initial Application       Amended Application (This supersedes all previous applications.)
Information About the Licensee
Name	 	

Hawaii Tax I.D. No.:  TO  	

DBA	

SSN/FEIN:  	

	

Address  	

Check one:		
	
  Wholesaler

	 
	
	 
	
 City or town    State   Postal/ZIP Code
Telephone number:  ______________________

  Dealer

	

Type of organization (e.g. Corporation, Partnership, Individual, etc.)
		

List the owners, partners, members, or principal corporate officers (Attach additional sheet if needed) Please print.
SSN/FEIN

Name

Title

Address

Phone No.

		
I declare, under the penalties set forth in section 231-36, HRS, that the information contained in this application has been
examined by me and, to the best of my knowledge and belief, is true and correct.
Signature of Owner, Partner, Member, or Principal Corporate Officer			

Print Name of Signatory	

Date

Title

DEPARTMENT OF TAXATION USE ONLY
	

Upon approval, the above named licensee is authorized to purchase Hawaii Cigarette Tax Stamps.

	

APPROVED BY                      Date:             

ID NO 01

FORM M-100A (REV. 2022)

FORM M-100A
(REV. 2022)	

Purpose of Form M-100A
Form M-100A is used to apply to purchase cigarette tax
stamps.

GENERAL INSTRUCTIONS
Sections 245-21 and 245-22, Hawaii Revised Statutes
(HRS), provide that licensees, as defined in section 245-1,
HRS, shall pay the cigarette tax through the use of cigarette
tax stamps and that licensees are required to place cigarette
tax stamps on packs of cigarettes prior to distribution, as
defined in section 245-1, HRS.

Signature
Form M-100A must be signed and dated by the Cigarette
and Tobacco Licensee.

Where to File Form M-100A
Form M-100A can be filed electronically at hitax.hawaii.
gov.
You may also mail Form M-100A to the following address:
Hawaii Department of Taxation
Tax Registration
P.O. Box 259
Honolulu, HI 96809-0259

Page 2

Where to Get Forms, Instructions, and
Publications
Forms, publications, and other documents, such as
copies of Tax Information Releases and Administrative Rules
issued by the Department, are available on the Department’s
website at tax.hawaii.gov or you may contact a customer
service representative at:
Voice:	808-587-4242
	
1-800-222-3229 (Toll-Free)
Telephone for the Hearing Impaired:
	808-587-1418
	
1-800-887-8974 (Toll-Free)
Fax:	808-587-1488
Mail:	 Taxpayer Services Branch
	
P. O. Box 259
	
Honolulu, HI 96809-0259