Form Ta-12 - Amended Transient Accommodations Tax Annual Return & Reconciliation
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1
2FORM TA-12
STATE OF HAWAII — DEPARTMENT OF TAXATION
DO NOT WRITE IN THIS AREA
27
(REV. 1998)
— AMENDED —
TRANSIENT ACCOMMODATIONS TAX
ANNUAL RETURN & RECONCILIATION
FOR CALENDAR YEAR _____
OR FISCAL YEAR ENDING ____/____/____
(For tax years beginning AFTER December 31, 1998)
T.A. REG. NO. __ __ __ __ __ __ __ __
NAME:
THIS FORM SHOULD BE USED ONLY AFTER THE ORIGINAL RETURN HAS BEEN FILED AND WITHIN THREE YEARS
OF THE DUE DATE OR FILING DATE OF THE ORIGINAL ANNUAL RETURN, WHICHEVER IS LATER.
GROSS RENTAL PROCEEDS OR
EXEMPTIONS/DEDUCTIONS
DISTRICT
TAXABLE PROCEEDS
RATE
TAXES
GROSS RENTAL
(EXPLAIN ON REVERSE SIDE)
a
b
c
d
TAXATION DISTRICT 1
1
.0725
1
(OAHU)
TAXATION DISTRICT 2
2
.0725
2
(MAUI, MOLOKAI, LANAI)
TAXATION DISTRICT 3
3
.0725
3
(HAWAII)
TAXATION DISTRICT 4
4
.0725
4
(KAUAI)
5
TOTAL TAXES DUE (ADD LINES 1 through 4 of column d, AND ENTER HERE)
5
6
PENALTY
6
7
INTEREST
7
8
TOTAL AMOUNT DUE (ADD LINES 5, 6, and 7; ENTER AMOUNT HERE.)
8
TOTAL TAXES PAID ON MONTHLY, QUARTERLY, OR SEMIANNUAL RETURNS
9
9
9
FOR THE PERIOD. PART III ON REVERSE SIDE MUST ALSO BE COMPLETED.
10
ADDITIONAL ASSESSMENTS PAID FOR THE PERIOD, IF INCLUDED ABOVE.
10
10
11
PENALTIES $ ______________ INTEREST $ ______________ PAID DURING THE PERIOD.
11
11
12
TOTAL PAYMENTS MADE (ADD LINES 9, 10, and 11)
12
12
13
CREDIT TO BE REFUNDED AS SHOWN ON ORIGINAL ANNUAL RETURN
13
13
14
NET PAYMENTS MADE (LINE 12 MINUS LINE 13)
14
15
IF LINE 14 IS LARGER THAN LINE 8, ENTER CREDIT TO BE REFUNDED (LINE 14 MINUS LINE 8)
15
16
IF LINE 8 IS LARGER THAN LINE 14, ENTER TAXES DUE (LINE 8 MINUS LINE 14)
16
17a Penalty
FOR LATE FILING ONLY
17
17b Interest
18
TOTAL AMOUNT NOW DUE AND PAYABLE (ADD LINES 16 AND 17)
18
PLEASE ENTER AMOUNT OF YOUR PAYMENT
19
19
(PAY IN U.S. DOLLARS ONLY)
20
GRAND TOTAL EXEMPTIONS/DEDUCTIONS FROM BACK OF FORM
20
MAKE CHECK PAYABLE TO
HAWAII STATE TAX COLLECTOR
IN U.S. DOLLARS DRAWN ON ANY U.S. BANK
WRITE YOUR T.A. REGISTRATION NUMBER ON THE CHECK
DECLARATION: I declare, under the penalties set forth in section 231-36, HRS, that this return, including any
accompanying schedules or statements, has been examined by me and, to the best of my knowledge and belief, is a
true, correct, and complete return, made in good faith for the taxable period stated, pursuant to the Transient
Accommodations Tax Law, Chapter 237D, HRS. I also reaffirm my statements on my operator’s registration (as
amended).
A CORPORATION OR PARTNERSHIP TAX RETURN MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT OF SUCH ENTITY.
SIGNATURE
TITLE
DATE
— MAILING ADDRESSES —
OAHU DISTRICT OFFICE
MAUI DISTRICT OFFICE
HAWAII DISTRICT OFFICE
KAUAI DISTRICT OFFICE
P.O. BOX 2430
P.O. BOX 1427
P.O. BOX 937
P.O. BOX 1687
HONOLULU, HI 96804-2430
WAILUKU, HI 96793-6427
HILO, HI 96721-0937
LIHUE, HI 96766-5687
THIS SPACE FOR DATE RECEIVED STAMP
27
FORM TA-12
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