Form A-6 - Tax Clearance Application - Hi Department Of Taxation - 2005

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Clear Form
FORM A-6
STATE OF HAWAII — DEPARTMENT OF TAXATION
(REV. 2005)
TAX CLEARANCE APPLICATION
PLEASE TYPE OR PRINT CLEARLY
FOR OFFICE USE ONLY
BUSINESS START DATE IN HAWAII
1. APPLICANT INFORMATION:
(PLEASE PRINT CLEARLY)
IF APPLICABLE
/
/
Applicant’s Name
HAWAII RETURNS FILED
IF APPLICABLE
Address
20______ 20______ 20______
________ ________ ________
City/State/Zip Code
STATE APPROVAL STAMP
DBA/Trade Name
This is not an
approved certificate
unless the State
2. TAX IDENTIFICATION NUMBER(S): (Complete applicable ID numbers)
approval stamp
appears here.
FEDERAL EMPLOYER ID #
-
(FEIN)
SOCIAL SECURITY #(SSN)
-
-
3. APPLICANT IS A/AN:
(CHECK ONLY ONE BOX)
*
IRS APPROVAL STAMP
£
£
£
CORPORATION
S CORPORATION
TAX EXEMPT ORGANIZATION
£
£
£
£
INDIVIDUAL
PARTNERSHIP
ESTATE
TRUST
£
£
LIMITED LIABILITY COMPANY
LIMITED LIABILITY PARTNERSHIP
£
Single Member LLC disregarded as separate from owner; enter owner’s FEIN/SSN
4. THE TAX CLEARANCE IS REQUIRED FOR:
£
£
*
*
CITY, COUNTY, OR STATE GOVERNMENT CONTRACT IN HAWAII
LIQUOR LICENSE
£
£
£
REAL ESTATE LICENSE
CONTRACTOR LICENSE
BULK SALES
CERTIFIED COPY STAMP
£
£
£
FINANCIAL CLOSING
PROGRESS PAYMENT
PERSONAL
£
£
£
HAWAII STATE RESIDENCY
FEDERAL CONTRACT
LOAN
£
£
SUBCONTRACT
OTHER
*
IRS APPROVAL STAMP IS ONLY FOR PURPOSES INDICATED BY ASTERISK .
£
5. NO. OF CERTIFIED COPIES REQUESTED:
6. SIGNATURE:
PRINT NAME
PRINT TITLE: Corporate Officer, General Partner or Member, Individual (Sole Proprietor), Trustee, Executor
(
)
-
(
)
-
SIGNATURE
DATE
TELEPHONE
FAX
POWER OF ATTORNEY. If submitted by someone other than a Corporate Officer, General Partner or Member, Individual (Sole Proprietor), Trustee, or Exec-
utor, a power of attorney (State of Hawaii, Department of Taxation, Form N-848) must be submitted with this application. If a Tax Clearance is required from
the Internal Revenue Service, IRS Form 8821, or IRS Form 2848 is also required. Applications submitted without proper authorization will be sent to the
address of record with the taxing authority. UNSIGNED APPLICATIONS WILL NOT BE PROCESSED.
PLEASE TYPE OR PRINT CLEARLY — THE FRONT PAGE OF THIS APPLICATION BECOMES THE CERTIFICATE UPON APPROVAL.
SEE PAGE 2 ON REVERSE & SEPARATE INSTRUCTIONS. Failure to provide required information on page 2 of this application or as required in the sepa-
rate instructions to this application will result in a denial of the Tax Clearance request.
(Page 1 of 2)

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