Form Hw-25 - Request For Agency Withholding And/or Submission Of Electronic Media For The Reporting Of Periodic Withholding Taxes

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STATE OF HAWAII — DEPARTMENT OF TAXATION
FORM
HW-25
REQUEST FOR AGENCY WITHHOLDING AND/OR
(Rev. 2000)
SUBMISSION OF ELECTRONIC MEDIA
FOR THE REPORTING OF PERIODIC WITHHOLDING TAXES
1.
Name
2. State Identification Number
3.
Business Address
4. Mailing Address
5.
Name of Contact Person regarding this request
Title
Phone Number
(
)
6.
I request permission to: (Check all that apply)
a.
File employer’s withholding tax return as agent for more than one employer. (Complete lines 8 AND 9)
b.
Use computer printouts with attachments to replace filing monthly or quarterly withholding tax returns. (Complete line 10)
c.
File monthly or quarterly withholding tax returns via electronic filing method.
7.
Period beginning: (Month, day, year — e.g., April 4, 1981 )
8.
Total number of participants:
9.
List of Participants. Complete this line if you checked box 6a. (If more space is needed, attach additional list.)
Employer’s
Filing
Withholding I.D.
Taxpayer’s Name
Dba name (if applicable)
Frequency
No.
As the tax return filing agent for these employers, I agree to keep copies of their required powers of attorney on file for examination by the Department of
Taxation on request. I will retain these copies until the power of attorney is revoked and the statute of limitations for their tax returns expires.
10. Required Attachments. Included with this request are the following: (Complete this line if you checked box 6b)
List of Participants
Magnetic "Test" Tapes
Summary Sheet Sample (computer printout)
Revocation List Sample
Individual Payment Lists Sample (computer printout)
which adhere to the Department of Taxation’s requirements in content and format.
Declaration and Signature: I request approval of the Director of
(For Departmental Use Only)
Taxation for the items checked on line 6 above. I agree to abide by the
law, the rules, and to furnish such information as the Director may deem
APPROVED:
6a
6b
6c
necessary to fulfill the requirements of the Department of Taxation.
DISAPPROVED:
6a
6b
6c
Signature
Signature
Name
Name
Title:
Title
Owner, Officer, Partner, Member, or duly authorized agent with power of attorney
Date
Date

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