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FORM
STATE OF HAWAII—DEPARTMENT OF TAXATION
THIS SPACE FOR DATE RECEIVED STAMP
M-22
QUARTERLY TAX RETURN FOR
ADDITIONAL FUEL TAXES DUE
(REV. 2010)
TO BE FILED BY END USER
FCF101
Name
Federal Employer I.D. No or Social Security No.
DBA or C/O
Hawaii Tax I.D. No.
W
__ __ __ __ __ __ __ __ - __ __
Address (Number and Street)
Period Beginning
___ ___ / ___ ___ (MM/YY)
City or Town, State, and Postal/ZIP Code. If foreign address, see Instructions.
Period Ending
___ ___ / ___ ___ (MM/YY)
NOTE: This return with payment must be submitted to the Department of Taxation on or before the 20th day of the month following the close of the fi ling period.
(a)
(b)
(c)
(d)
(e)
CITY & COUNTY
COUNTY OF
COUNTY OF
COUNTY OF
TYPES OF LIQUID FUEL
TOTAL TAXES DUE
OF HONOLULU
MAUI
HAWAII
KAUAI
(add cols. a thru d)
PART I — DIESEL OIL
c
1. (a) Gallons purchased where only 2¢
tax previously paid
(b) Tax Rate
31.5¢
31¢
23.8¢
28¢
(c) Additional Tax Due. Multiply line 1(a)
1c
by 1(b) of cols. a thru d
2. (a) Gallons purchased where NO tax
was previously paid
c
c
c
c
(b) Tax Rate
33.5¢
33¢
25.8¢
30¢
(c) Additional Tax Due. Multiply line 2(a)
2c
by 2(b) of cols. a thru d
3. TOTAL DIESEL OIL TAX DUE — Add column (e), lines 1(c) and 2(c) ....................................................................................
3
PART II — ALTERNATIVE FUEL
4. (a) Type/Gallons purchased where NO
tax was previously paid
(b) Tax Rate (see instructions)
(c) Additional Tax Due. Multiply line 4(a)
4c
by 4(b) of cols. a thru d
PART III — NAPHTHA
d
5. (a) Gallons purchased where only 1¢
e
or 2¢
tax previously paid
(b) Tax Rate
32.5¢/31.5¢
32¢/31¢
24.8¢/23.8¢
29¢/28¢
(c) Additional Tax Due. Multiply line 5(a)
5c
by 5(b) of cols. a thru d
6. (a) Gallons purchased where NO tax
was previously paid
c
c
c
c
(b) Tax Rate
33.5¢
33¢
25.8¢
30¢
(c) Additional Tax Due. Multiply line 6(a)
6c
by 6(b) of cols. a thru d
7. TOTAL NAPHTHA TAX DUE — Add column (e), lines 5(c) and 6(c)........................................................................................
7
8. TOTAL TAXES NOW DUE & PAYABLE — Add column (e), lines 3, 4(c), and 7. Enter the amount here.
Include a check or
money order payable to “HAWAII STATE TAX COLLECTOR” in U.S. dollars with this form. Write “fuel”, the period ending date, and your FEIN or SSN on
8
your check or money order. Mail to: HAWAII DEPARTMENT OF TAXATION, P. O. BOX 259, HONOLULU, HI 96806-0259.
Continue on page 2
FORM M-22