Form M-22 - Quarterly Statement And Tax Return Of Liquefied Petroleum Gas Initially Purchased For Use Off The Public Highways But Subsequently Used On The Public Highways

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TO BE FILED
FORM M-22
(REV. 1999)
BY USER
STATE OF HAWAII—DEPARTMENT OF TAXATION
QUARTERLY STATEMENT AND TAX RETURN OF LIQUEFIED PETROLEUM GAS
INITIALLY PURCHASED FOR USE OFF THE PUBLIC HIGHWAYS
BUT SUBSEQUENTLY USED ON THE PUBLIC HIGHWAYS
(Chapter 243, HRS)
Period Covered
,
Used in the County of
(See Line 9)
Federal Employer ID Number or Social Security Number
(GALLONS)
STATEMENT OF FUEL TRANSACTIONS AND TAX DUE:
1. On hand at beginning of period.......................................................................................................................
2. Purchases or other acquisition........................................................................................................................
3. Total (Add lines 1 and 2) .................................................................................................................................
4. USED IN OPERATING MOTOR VEHICLES UPON THE PUBLIC HIGHWAYS:
(a) PURCHASES—TAX ONLY 1¢ PAID......................................................................................................
(b) PURCHASES—TAX UNPAID ................................................................................................................
(c) PURCHASES—TAX FULLY PAID .........................................................................................................
5. Used in internal combustion engines, operating motor vehicles off the public highways or other purposes .
6. Total [ Add lines 4(a), 4(b), 4(c), and 5] ..........................................................................................................
7. On hand at end of period (Line 3 minus Line 6)..............................................................................................
8. TAX ON GALLONS USED AS SHOWN ON LINE 4(a)
(Sch. A Tax rates on reverse page) ....................................................................$
TAX ON GALLONS USED AS SHOWN ON LINE 4(b)
(Sch. B Tax rates on reverse side)......................................................................$
$
9. If used in more than one county, show number of gallons used in each........................................................
(Specify Lanai or Molokai separately)
(Lines 1 through 3 and Lines 5 through 7 may be disregarded if separate records are maintained for liquefied petroleum gas used for
each piece of motor vehicle.)
I declare, under the penalties set forth in section 231-36, HRS, that this
NAME
is a true and correct return, prepared in accordance with the provisions
of the Fuel Tax Law and the rules issued thereunder.
ADDRESS
City
State
Zip Code
SIGNATURE _____________________________________________________________
NOTE: This return with payment must be submitted to the Hawaii
TITLE __________________________________________________________________
State Tax Collector in your taxation district on or before the
last day of the month following the close of the filing period.
DATE __________________________________________________________________
FORM M-22

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