FORM M-19
Page 3
(REV. 2006)
PART II - REFUND OF CIGARETTE TAX PAID WITH CIGARETTE TAX STAMPS
SCHEDULE 1 - CIGARETTES SHIPPED OUTSIDE OF THE STATE FOR SALE OR USE OUTSIDE THE STATE
Attach copy of Form M-104, Export Exemption Certificate for Cigarette and Tobacco Taxes
Number of Cigarettes
Number of Packages
Number of Cigarette Tax
Value
Amount of Refund
per Package
Shipped Outside Hawaii
Stamps on Package
(C) x $1.60
(B) x (D)
(A)
(B)
(C)
(D)
(E)
20
1
$1.60
$
Other than 20
$
1. Refund (Add all amounts in column E)
$
SCHEDULE 2 - CIGARETTES WHICH BECAME THE SUBJECT OF A CASUALTY LOSS
Attach copy of claim of loss to insurance company for inventory lost or destroyed
Number of Cigarettes
Number of Packages
Number of Cigarette Tax
Value
Amount of Refund
per Package
Subject to a Casualty
Stamps on Package
(C) x $1.60
(B) x (D)
Loss
(A)
(B)
(C)
(D)
(E)
20
1
$1.60
$
Other than 20
$
2. Refund (Add all amounts in column E)
$
SCHEDULE 3 - STALE CIGARETTES RETURNED TO MANUFACTURER
Attach copy of certification from manufacturer for return of stale cigarettes.
TABLE 1: Use Table 1 for cigarette packages with blue or pink stamps which were distributed (as defined in section 245-1, HRS) after June 30, 2004, and prior to September 30, 2006. See instructions.
Number of Cigarettes
Serial Number of
Number of Packages
Number of Cigarette
Value
Amount of Refund
per Package
Stamps
Returned to the
Tax Stamps
(D) x $1.40
(C) x (E)
Manufacturer
on Package
(B)
(C)
(D)
(E)
(A)
(F)
20
1
$1.40
$
Other than 20
$
3a. Refund (Add all amounts in Column F)
$
TABLE 2: Use Table 2 for cigarette packages with orange or blue stamps which were distributed (as defined in section 245-1, HRS) after September 29, 2006. See instructions.
Number of Cigarettes
Serial Number of
Number of Packages
Number of Cigarette
Value
Amount of Refund
per Package
Stamps
Returned to the
Tax Stamps
(D) x $1.60
(C) x (E)
Manufacturer
on Package
(B)
(C)
(D)
(E)
(A)
(F)
20
1
$1.60
$
Other than 20
$
3b. Refund (Add all amounts in Column F)
$
SCHEDULE 4 - OVERPAYMENT OF TAX ON CIGARETTE PACKAGES CONTAINING MORE THAN 20 CIGARETTES
Number of Cigarettes
Tax on Package
Number of Cigarette Tax
Value
Amount of Refund
per Package
of Cigarettes
Stamps on Package
(C) x $1.60
[(D) - (B)] x Number of
(A) x $.08
Cigarette Packages
(A)
(B)
(C)
(D)
(E)
$
$
$
$
$
$
4. Refund (Add all amounts in column E)
$
SCHEDULE 5 - REFUND FOR DAMAGED CIGARETTE TAX STAMPS AFFIXED TO CIGARETTE PACKAGES
Proof of damaged cigarette tax stamps shall be offered for inspection and examination at any time upon request of the Department of Taxation or the
Department of the Attorney General. See instructions.
5. Number of cigarette tax stamps that were damaged while being affixed to the cigarette packages
x $1.60 =
$
6. Total refund of cigarette tax paid with cigarette tax stamps. Add lines 1, 2, 3a, 3b, 4, and 5. Enter total here and on page 1, line 8 $