Form M-103 - Transfer Of Cigarette Tax Stamps
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FORM M-103
STATE OF HAWAII - DEPARTMENT OF TAXATION
(REV. 2013)
TRANSFER OF CIGARETTE TAX STAMPS
PART I
Information About the Licensee Transferring the Cigarette Tax Stamps
Name
Cigarette Tax Stamps Purchase Approval Number (Assigned on Form M-100A) CIG-
Hawaii Tax Identification Number: W __ __ __ __ __ __ __ __ - __ __
Address
City or town
State
Postal/Zip Code
PART II
Information About the Licensee Receiving the Cigarette Tax Stamps
Name
Cigarette Tax Stamps Purchase Approval Number (Assigned on Form M-100A) CIG-
Address
City or town
State
Postal/Zip Code
PART III Transfer of Cigarette Tax Stamps
A. Serial number of the stamps being transferred
B. Number of stamps being transferred
C. Multiply amount from line B, Part III, by $3.20 and enter here
D. Reason for the transfer
Signature of Licensee Transferring the Cigarette Tax Stamps
Signature of Licensee Receiving the Cigarette Tax Stamps
Print Name of Signatory
Print Name of Signatory
Title
Date
Title
Date
FOR OFFICIAL USE ONLY:
Transfer of Cigarette Tax Stamps Approved
Transfer of Cigarette Tax Stamps Disapproved
Signature
Title
Date
THIS SPACE FOR DATE RECEIVED STAMP
FORM M-103
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