Clear Form
STATE OF HAWAII — DEPARTMENT OF TAXATION
FORM M-2
(REV. 2004)
CERTIFICATE OF RETAIL SALES OF LIQUID FUEL
Name Of Licensed Distributor From Whom The Liquid Fuel Was Purchased
Date of this Certificate
NOTE: Prepare this form
in DUPLICATE:
F Original shall be
Name of Retail Dealer
Liquid Fuel Retail Dealer's Permit No.
Please
retained by the
Print
licensed
Business address (Number and Street)
FEIN or SSN (if any)
or
distributor.
F Copy to be
Type
City, State, ZIP code
RETAIL SALES FOR THE MONTH OF (mo/yr)
retained by the
retail dealer.
(a)
(b)
(c)
(d)
(e) Add cols. b thru d
(f)
(g)
TYPES OF LIQUID FUEL*
CITY AND COUNTY
TOTALS
ISLAND OF MAUI
ISLAND OF LANAI
ISLAND OF MOLOKAI
COUNTY OF HAWAII
COUNTY OF KAUAI
Show Number of Gallons
OF HONOLULU
COUNTY OF MAUI
1) Aviation·················································
2) Diesel····················································
3) Alternative Fuel·····································
4) Gasoline — Premium ···························
Regular·····························
Unleaded ··························
Others·······························
____________________ ·
____________________ ·
5) Total Gallons By County ·······················
*Note: THE INFORMATION IS NEEDED BY THE DISTRIBUTOR TO COMPLETE ITS FUEL TAX RETURN.
Alternative Fuel Definition: “Alternative fuel” means methanol, denatured ethanol, and other alcohols; mixtures containing 85 percent or more by volume of methanol, denatured ethanol, and other alcohols with
gasoline or other fuels; natural gas; liquefied petroleum gas; hydrogen; coal-derived liquid fuels; biodiesel; mixtures containing 20 percent or more by volume of biodiesel with diesel or other fuels; fuels (other than al-
cohol) derived from biological materials; and any other fuel that is substantially not a petroleum product and that the governor determines would yield a substantial energy security benefits or substantial environmen-
tal benefits. Effective for taxable years beginning after December 31, 2001. (Act 143, SLH 2001)
DECLARATION BY RETAIL DEALER
I declare, for myself and for the above named retail dealer, under the penalties provided by Section 243-3(b), HRS, the undersigned hereby certifies that:
• the permittee is the holder of a valid permit which is still in effect;
• the statements made in the permit application are true, correct and complete as of this date;
• the permittee is maintaining the practices and records set forth in the application; and
• to the best of my knowledge and belief this certificate is a true, correct and complete statement for the above mentioned period.
Name of Signatory
Signature
Title
Date
Licensed Distributors — Complete Page 2 of this Form
FORM M-2
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