Form X-4 - Application For Reinstatement - State Of Hawaii Department Of Commerce And Consumer Affairs

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FORM X-4
7/2012
STATE OF HAWAII
STATE OF HAWAII
Nonrefundable Filing Fee:
Profit Corporation: $25.00
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
*X4*
Nonprofit Corporation: $10.00
General Partnership: $10.00
Business Registration Division
Business Registration Division
LLP: $25.00
335 Merchant Street
335 Merchant Street
Limited Partnership: $10.00
LLLP: $10.00
Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810
Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810
LLC: $25.00
Phone No. (808) 586-2727
Phone No. (808) 586-2727
Clear Form
APPLICATION FOR REINSTATEMENT
APPLICATION FOR REINSTATEMENT
(Section 414-403, 415A-18, 414D-250, 425-14, 425-164, 425E-810, 428-811, Hawaii Revised Statutes)
(Section 414-403, 415A-18, 414D-250, 425-14, 425-164, 425E-810, 428-811, Hawaii Revised Statutes)
PLEASE TYPE OR PRING LEGIBLY IN BLACK INK
The undersigned, submitting this application for reinstatement, certify as follows:
1.
The entity is (check one):
Profit Corporation
Nonprofit Corporation
General Partnership
Limited Liability Partnership
(F/$25/B15)
(F/$10/B15)
(F/$10/B29)
(F/$25/L34)
Limited Partnership
Limited Liability Limited Partnership
Limited Liability Company
(F/$10/B31)
(F/$10/B31)
(F/$25/L14)
2.
Name of business entity:
(Corporation, Partnership, LLC Name)
3.
the business entity was involuntarily dissolved/canceled/revoked or administratively terminated/dissolved/canceled by
Decree/Order issued by the Director of Commerce and Consumer Affairs on:
(Month
Day
Year)
4.
Attached are the delinquent annual statements/reports for the years:
,
,
,
,
,
.
,
,
,
.
5.
Attached is a certificate or other writing from the Department of Taxation, State of Hawaii, indication that all taxes have
been paid, or that a payment arrangement has been entered into, or the unpaid tax liabilities are being contested in an
administrative or judicial appeal with the department of taxation.
6.
Attached is payment for all delinquent fees, penalties and other costs in the amount of $
.
I/we certify under the penalties of Section 414-20, 414D-12, 425-13, 425-172, 425E-208 and 428-1302, Hawaii Revised
Statutes, as applicable, that I/we have read the above statements, I/we are authorized to to sign this application, and that the
above statements are true and correct.
Signed this
day of
,
(Type/Print Name & Title)
(Type/Print Name & Title)
(Signature)
(Signature)
SEE INSTRUCTIOMS ON REVERSE SIDE

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