Form M-105 - Schedule Of Imported Foreign Cigarettes To Which Cigarette Tax Stamps Have Been Affixed

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Clear Form
Prepare in triplicate
1- Tax Department
STATE OF HAWAII - DEPARTMENT OF TAXATION
FORM M-105
(Rev. 2010)
2- Attorney General
3- Your files
SCHEDULE OF IMPORTED FOREIGN CIGARETTES
TO WHICH CIGARETTE TAX STAMPS HAVE BEEN AFFIXED
Report For the Month of _________________ Year _______
1.
Licensee’s name ____________________________________________________________
2.
Licensee’s Cigarette Tax and Tobacco Tax License No. _____________________________
Hawaii Tax Identification Number: W __ __ __ __ __ __ __ __ - __ __
3.
The following items MUST be attached to this schedule:
4.
A.
A copy of a permit issued pursuant to section 5713 of the Internal Revenue Code to the person
importing the cigarettes into the United States, permitting the person to import the cigarettes.
B.
A copy of the United States Customs Service form containing, with respect to the cigarettes, the
federal tax information required by the United States Bureau of Alcohol, Tobacco and Firearms.
In the upper right-hand corner of the copies, write the corresponding line reference to identify the
cigarettes from the list below.
Quantity
Name of Supplier
Name of Customer
No.
Brand
Style
1
2
3
4
5
Attach an additional sheet if more space is needed.
As an authorized representative of the licensee, I declare, under penalties of perjury, that I have examined this
schedule and to the best of my knowledge and belief, the information provided is true, correct, accurate and
complete.
Signature ________________________________________ Date __________________________
Print Name _______________________________________ Title _________________
As an officer of the manufacturer or importer of the cigarettes listed above, I certify, under penalty of perjury
and the penalties set forth in section 231-36, Hawaii Revised Statutes (HRS), that the manufacturer or
importer of cigarettes listed above has complied with (1) the package health warning and ingredient reporting
requirements of the Federal Cigarette Labeling and Advertising Act, 15 U.S.C. sections 1333 and 1335a, with
respect to the cigarettes; and (2) chapter 675, HRS.
Is the manufacturer a participating manufacturer within the meaning of section 675-3, HRS? ¨ Yes ¨ No
(Note: Must check one of the boxes.)
Signature _________________________________________ Date __________________________
Print Name ____________________________________ Title _________________
FORM M-105

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