Form M-2 - Certificate Of Retail Sales Of Liquid Fuel

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FORM M-2

STATE OF HAWAII — DEPARTMENT OF TAXATION

(REV. 2013)

CERTIFICATE OF RETAIL SALES OF LIQUID FUEL

Name Of Licensed Distributor From Whom The Liquid Fuel Was Purchased

Date of this Certificate

NOTE:

Prepare this form

in DUPLICATE:

Name of Retail Dealer

Liquid Fuel Retail Dealer’s Permit Number



Original shall be

Please

retained by the

licensed

Address (Number and Street)

Federal Employer I.D. No. or Social Security Number

distributor.

Type



Copy to be

City, State, Postal/ZIP code

RETAIL SALES FOR THE MONTH OF (MM/YY)

retained by the

retail dealer.

TYPES OF LIQUID FUEL*

(a)

(d)

(e) Add cols. b thru d

(b)

(c)

(f)

(g)

CITY AND COUNTY

ISLAND OF

TOTALS

Show Number of Gallons

ISLAND OF MAUI

ISLAND OF LANAI

COUNTY OF HAWAII

COUNTY OF KAUAI

OF HONOLULU

MOLOKAI

COUNTY OF MAUI

1) Aviation............................................

2) Diesel

2a) Used in small boats................

2b) Used for all other purposes....

3) Naphtha - Power-Generating Facility

4) Alternative Fuel

Biodiesel.......................................

Compressed Natural Gas.............

Ethanol.........................................

Liquefied Natural Gas..................

LPG..............................................

Methanol......................................

5) Gasoline

5a) Used in small boats................

5b) Used for all other purposes....

6) Total Gallons By County...................

*Note: THE INFORMATION IS NEEDED BY THE DISTRIBUTOR TO COMPLETE ITS FUEL TAX RETURN.

DECLARATION BY RETAIL DEALER

I declare, for myself and for the above named retail dealer, under the penalties provided by Section 243-3(b), HRS, the undersigned hereby certifies that:

• the permittee is the holder of a valid permit which is still in effect;

• the statements made in the permit application are true, correct, and complete as of this date;

• the permittee is maintaining the practices and records set forth in the application; and

• to the best of my knowledge and belief this certificate is a true, correct, and complete statement for the above mentioned period.

Name of Signatory

Signature

Title

Date

Licensed Distributors — Complete Page 2 of this Form