Hawaii Export Exemption Certificate for Cigarette and Tobacco Taxes

Export Exemption Certificate for Cigarette and Tobacco Taxes
Form M-104, Rev 2019, Export Exemption Certificate for Cigarette and Tobacco Taxes
Clear Form

STATE OF HAWAII — DEPARTMENT OF TAXATION

FORM M-104
(Rev. 2019)

PART I	

EXPORT EXEMPTION CERTIFICATE
FOR CIGARETTE AND TOBACCO TAXES

Information About the Cigarette
and Tobacco Licensee

PART II	 Information About the Purchaser,
Consumer, or User

Name	 	

Name		

Address	

Address	

	

	

	

	

	

	
City or town	

	

	
City or town	

State	

Postal/Zip Code

State	

Postal/Zip Code

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

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

		

		

Hawaii Tax I.D. No.:
TO                 

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 AND TOBACCO LICENSEE; AND
PURCHASER, CONSUMER, OR USER
The undersigned Cigarette and Tobacco 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 and Tobacco 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 and Tobacco 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 and Tobacco 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 and Tobacco Licensee signature

Print name of signatory	

Purchaser, consumer, or user signature

Title	

Date

Print name of signatory	

Title	

Date

FORM M-104
M104_I 2019A 01 VID01

ID NO 01

FORM M-104
INSTRUCTIONS
(Rev. 2019)

GENERAL INFORMATION
Section 245-32, Hawaii Revised
Statutes (HRS), provides for a cigarette
and tobacco tax refund or credit to a licensee who has paid a cigarette or tobacco tax on the distribution of cigarettes or tobacco products that are
shipped to a point outside the State for
subsequent sale or use outside the
State.

ADDITIONAL INFORMATION
Export and Foreign Cigarettes
Prohibited
It is unlawful for an entity to possess,
keep, store, retain, transport, sell, or offer to sell, distribute, acquire, hold, own,
import, or cause to be imported into the
State any of the cigarettes described in
section 245-51, HRS.

Stamping or Sale of Cigarettes
Not Listed in the Directory
Prohibited
Unless the cigarette package is exempt under section 245-3(b), HRS, it is
unlawful (a) to affix a cigarette tax
stamp to any cigarette package whose
tobacco product manufacturer or brand
family is not listed in the directory established under chapter 486P, HRS, or
(b) to import, sell, offer, keep, store, acquire, transport, distribute, receive, or
possess for sale or distribution cigarettes of a tobacco product manufacturer or brand family not included in the
directory. Any entity in violation will be
guilty of a class C felony.
To determine whether the cigarette
manufacturer or brand family is listed in
such directory, please visit the Tobacco
Enforcement Unit, Department of the
Attorney
General’s
website
at:
ag.hawaii.gov/cjd/tobacco-enforcement-unit

The Tobacco Enforcement Unit also
may be contacted as follows:
Correspondence:
TOBACCO ENFORCEMENT UNIT
Department of the Attorney General
425 Queen Street
Honolulu, Hawaii 96813
Telephone: (808) 586-1203

PURPOSE OF THIS
CERTIFICATE
Form M-104, Export Exemption Certificate for Cigarette and Tobacco Taxes, must be completed in order for the
Cigarette and Tobacco Licensee to
claim a (1) cigarette tax refund, or (2)
tobacco tax exemption on the distribution of cigarettes or tobacco products
that are shipped to a point outside the
State for subsequent sale or use outside the State. Form M-104 must also
be completed for sales made under
section 212-8, HRS, to any common
carrier for consumption out-of-state by
the crew or passengers on such carrier,
and for sales by wholesalers from U.S.
licensed bonded warehouses to foreign
fishing vessels and to common carriers
for out-of-state consumption by the
crew or passengers. This form must be
a part of each order or contract of sale
between the Cigarette and Tobacco Licensee; and purchaser, consumer, or
user who are signatories to the certificate. In the event Form M-104 is impracticable to complete, an alternative
form or document may be used provided the information requested in Parts I,
II, and III of Form M-104 are maintained.

SPECIFIC INSTRUCTIONS
Part I
Enter information regarding the Cigarette and Tobacco Licensee.

Part II
Enter information regarding the purchaser, consumer, or user.
Part III
Enter information regarding the cigarettes or tobacco products involved in
this transaction.
SIGNING OF THE CERTIFICATE
The certificate shall be dated, executed, and signed by both the Cigarette
and Tobacco Licensee; and the purchaser, consumer, or user.

WHERE TO FILE THE
CERTIFICATE
The certificate must be attached to
the Cigarette and Tobacco Licensee’s
Form M-19, Cigarette and Tobacco
Products Monthly Tax Return, when
claiming a refund of cigarette taxes
paid with cigarette tax stamps. The certificate does not need to be attached to
Form M-19 when claiming a tobacco
tax exemption. Instead, the certificate
must be retained at the Cigarette and
Tobacco Licensee’s place of business.

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