Form N-172 - Claim For Tax Exemption By Person With Impaired Sight Or Hearing Or By Totally Disabled Person And Physician'S Certification

Download a blank fillable Form N-172 - Claim For Tax Exemption By Person With Impaired Sight Or Hearing Or By Totally Disabled Person And Physician'S Certification in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form N-172 - Claim For Tax Exemption By Person With Impaired Sight Or Hearing Or By Totally Disabled Person And Physician'S Certification with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Clear Form
FORM
N-172
STATE OF HAWAII — DEPARTMENT OF TAXATION
(REV. 2012)
Claim for Tax Exemption by Person with Impaired Sight
or Hearing or by Totally Disabled Person and Physician’s Certification
(NOTE: References to “married”, “unmarried”, and “spouse” also means “in a civil union”, “not in a civil union”, and “civil union partner”, respectively.)
If you are submitting Form N-172 in response to either an adjustment letter or a collection notice, please check here
ä
Part I
Claim for tax exemption
INDIVIDUAL:
CORPORATION, PARTNERSHIP, or LLC:
Name of Individual
Name of Corporation, Partnership, or LLC
Individual’s Social Security No.
Spouse’s Social Security No.
Federal Employer I.D. No.
Street Address of Individual
Street Address
City, State & Postal/ZIP Code
City, State & Postal/ZIP Code
all of whose shareholders, partners, or members are individuals who are
(check all applicable categories)
who is (check applicable category)
A person who is blind as defined in sec. 235-1, HRS,
Blind as defined in sec. 235-1, HRS,
A person who is deaf as defined in sec. 235-1, HRS,
Deaf as defined in sec. 235-1, HRS,
A person totally disabled as defined in sec. 235-1, HRS,
Person totally disabled as defined in sec. 235-1, HRS,
hereby claim the benefits provided under the General Excise Tax and/or Income Tax Laws. (Check all applicable categories and provide the information
requested. See separate instructions for the definitions of blind, deaf, and person totally disabled.)
General Excise Tax (sections 237-17 and 237-24(13), HRS)
(a) General Excise Hawaii Tax I.D. No. W ___ ___ ___ ___ ___ ___ ___ ___ - ___ ___
(b) Doing Business As (DBA)
(c)
Business Address
(d) Type of Business Activity
(e) Individual’s Percentage of Ownership:
; Spouse’s percentage
Income Tax (section 235-54, HRS) (for individuals only)
(a) Name on tax return (if joint, show both names)
I declare, under the penalties set forth in section 231-36, HRS, that I have examined/understand the detail contents of this claim and to the best
of my knowledge and belief, it is true, correct, and complete.
IN THE CASE OF A CORPORATION, PARTNERSHIP, OR LLC, THIS FORM MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT.
Taxpayer Signature (individual, corporate officer, partner or member, or duly authorized agent)
Date
Title
NOTE: DISABILITY OR IMPAIRMENT MUST BE CERTIFIED BY LICENSED PHYSICIANS,
OPTOMETRISTS, ETC., ON THE BACK OF THIS FORM.
FORM N-172

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2