Form N-172 - Claim For Tax Exemption By Person With Impaired Sight Or Hearing Or By Totally Disabled Person And Physician'S Certification - 2016

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FORM
N-172
STATE OF HAWAII — DEPARTMENT OF TAXATION
(REV. 2016)
Claim for Tax Exemption by Person with Impaired Sight
or Hearing or by Totally Disabled Person and Physician’s Certification
(NOTE: References to “married” and “spouse” are also references to “in a civil union” and “civil union partner,” respectively.)
If you are submitting Form N-172 in response to either an adjustment letter or a collection notice, please check here
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Part I
Claim for tax exemption
INDIVIDUAL:
CORPORATION, PARTNERSHIP, or LLC:
Name of Individual
Name of Corporation, Partnership, or LLC
Individual’s Social Security No.
Spouse’s Social Security No.
Federal Employer I.D. No.
Street Address of Individual
Street Address
City, State & Postal/ZIP Code
City, State & Postal/ZIP Code
all of whose shareholders, partners, or members are individuals who are
(check all applicable categories)
who is (check applicable category)
A person who is blind as defined in sec. 235-1, HRS,
Blind as defined in sec. 235-1, HRS,
A person who is deaf as defined in sec. 235-1, HRS,
Deaf as defined in sec. 235-1, HRS,
A person totally disabled as defined in sec. 235-1, HRS,
Persons totally disabled as defined in sec. 235-1, HRS,
hereby claims the benefits provided under the General Excise Tax and/or Income Tax Laws. (Check all applicable categories and provide the information
requested. See separate instructions for the definitions of blind, deaf, and person totally disabled.)
General Excise Tax (sections 237-17 and 237-24(13), HRS)
(a) General Excise Hawaii Tax I.D. No. GE ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ - ___ ___
(b) Doing Business As (DBA)
(c)
Business Address
(d) Type of Business Activity
(e) Individual’s Percentage of Ownership:
; Spouse’s percentage:
Income Tax (section 235-54, HRS) (for individuals only)
(a) Name on income tax return (if joint, show both names)
I declare, under the penalties set forth in section 231-36, HRS, that I have examined/understand the detail contents of this claim and to the best
of my knowledge and belief, it is true, correct, and complete.
IN THE CASE OF A CORPORATION, PARTNERSHIP, OR LLC, THIS FORM MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT.
Taxpayer Signature (individual, corporate officer, partner or member, or duly authorized agent)
Date
Title
NOTE: DISABILITY OR IMPAIRMENT MUST BE CERTIFIED BY LICENSED PHYSICIANS,
OPTOMETRISTS, ETC., ON THE BACK OF THIS FORM.
FORM N-172

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