Form M-106 - Request For Refund Of Unused Cigarette Tax Stamps - State Of Hawaii - Department Of Taxation

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FORM M-106
STATE OF HAWAII - DEPARTMENT OF TAXATION
(REV. 2006)
REQUEST FOR REFUND OF UNUSED
CIGARETTE TAX STAMPS
Caution: Use Form M-106 (Rev. 2006) for refunds requested on and after September 30, 2006. For refunds requested
before September 30, 2006, use Form M-106 (Rev. 2005).
Name of Cigarette Licensee
Cigarette Tax Stamps Approval Number (Assigned on Form M-100A)
Address
City
State
Zip Code
Number of unused cigarette tax stamps being returned . . . . . . . . . . . . . . . . .
Stamps @ $1.60 each . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
x $1.60
Total amount of refund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Serial number of the stamps being returned
Reason stamps are being returned
Cigarette Tax and Tobacco Tax Licensee signature
Title
Print name of signatory
Date
FOR DEPARTMENT OF TAXATION USE ONLY:
Approved by Collection Branch
Date
Approved by Revenue Accounting Branch
Date
FORM M-106

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