Form M-106 - Request For Refund Of Unused Cigarette Tax Stamps

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FORM M-106
STATE OF HAWAII - DEPARTMENT OF TAXATION
(REV. 2011)
REQUEST FOR REFUND OF UNUSED
CIGARETTE TAX STAMPS
Caution: Use Form M-106 (Rev. 2011) for refunds requested on and after July 1, 2011. For refunds requested
before July 1, 2011, use Form M-106 (Rev. 2010).
Name of Cigarette Licensee
Cigarette Tax Stamps Approval Number (Assigned on Form M-100A)
Hawaii Tax Identification Number: W __ __ __ __ __ __ __ __ - __ __
Address
City
State
Postal/Zip Code
Number of unused cigarette tax stamps being returned. . . . . . . . . . . . . . . . .
Stamps @ $3.20 each . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
x $3.20
Total amount of refund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Serial number of the stamps being returned
Reason stamps are being returned
Cigarette Tax and Tobacco Tax Licensee signature
Title
Print name of signatory
Date
FOR DEPARTMENT OF TAXATION USE ONLY:
Approved by Collection Branch
Date
Approved by Revenue Accounting Branch
Date
FORM M-106

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