Form G-39 -Application For Extension Of Time To File The Annual Return And Reconciliation General Excise/use Tax - 2001

DO NOT WRITE IN THIS AREA

FORM G-39

(REV. 2001)

STATE OF HAWAII — DEPARTMENT OF TAXATION

APPLICATION FOR EXTENSION OF TIME TO FILE

THE ANNUAL RETURN AND RECONCILIATION

GENERAL EXCISE/USE TAX (FORM G-49)

Please read instructions below before preparing form.

TAXPAYER’S

NAME

________________________________________________

BUSINESS

GENERAL EXCISE/USE I.D. No.

NAME (DBA)

__________________________________________

ADDRESS

_______________________________________________

_____ _____ _____ _____ _____ _____ _____ _____

________________________________________________

ZIP CODE + 4

_______________________

APPLICATION is hereby made for an extension of time to file the general excise and use tax annual return and reconciliation (Form G-49):

a. For:

b. An extension is requested until:

(No more than 3 months. See Instructions below.)

calendar year ending December 31, 20 ______

fiscal year ending

_______ / ______ / ______

DAY

c. Were you previously granted an extension of time to file this return?

Yes

If yes, previous extension was granted to

_______/ _______ / _______

DAY

d. This extension is necessary for the following reasons (see instructions below):

____________________________________________________________________________________________________________________

e. ADDITIONAL TAXES DUE (See Instructions below) Attach a check or money order for this amount in U.S. dollars

payable to “HAWAII STATE TAX COLLECTOR.” Write your general excise/use I.D. number on the check. If no

payment is due, enter “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DECLARATION

I declare under the penalties set forth in section 231-36, HRS, that the statements contained herein are true and correct.

SIGNATURE OF TAXPAYER OR AUTHORIZED AGENT WITH POWER OF ATTORNEY

DATE

INSTRUCTIONS FOR PREPARATION OF THIS FORM

NOTE: This form may be electronically filed (e-filed) with the Department of Taxation. For more information, go to our website at

and select “Electronic Business Information: Internet & Electronic Filing.”

1. Extensions will only be granted for 3 months or less. See 6 below if additional extensions are needed.

2. Extensions will only be granted for a good reason (e.g., hospitalization of taxpayer). A full explanation of the reasons you need an extension must be given.

3. This extension of time to file is NOT AN EXTENSION OF TIME TO PAY. If additional general excise and use taxes are due for the year, write the amount due

on line e. Your check or money order for the entire amount, payable in U.S. dollars to the “HAWAII STATE TAX COLLECTOR,” must be attached to this form.

4. Submit the completed form to the taxation district with which you are registered ON OR BEFORE THE ORIGINAL DUE DATE OF THE RETURN. Applications

for extensions filed after that date will not be granted.

5. IMPORTANT — Approved applications for extensions are ONLY valid if all monthly, quarterly, or semiannual periodic returns (Form G-45) for the year have

been filed.

6. ADDITIONAL extensions of time to file the general excise/use tax annual return and reconciliation beyond the initial 3-month period may be requested by

completing this form and submitting it to the taxation district with which you are registered before the expiration of the initial 3-month extension.

7. IMPORTANT — The total period for which extensions will be granted cannot exceed six (6) months.

MAILING ADDRESSES

THIS SPACE FOR DATE RECEIVED STAMP

(Please direct all inquiries and correspondence to the district tax office with which you are

registered.)

OAHU DISTRICT OFFICE

HAWAII DISTRICT OFFICE

P.O. Box 1425

P.O. Box 937

Honolulu, HI 96806-1425

Hilo, HI 96721-0937