Form M-22 - Quarterly Tax Return For Additional Fuel Taxes Due Page 2

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FORM M-22 (REV. 2015)

PAGE 2

Name

FEIN or SSN

Period Ending (MM/YY)

___ ___ / ___ ___ (MM/YY)

FCF152

PART IV — SUMMARY OF GALLONS IN THE COUNTY OF MAUI

(d)

(a)

(b)

(c)

TOTAL GALS. FOR

TYPES OF LIQUID FUEL

ISLAND OF LANAI

ISLAND OF MOLOKAI

ISLAND OF MAUI

COUNTY OF MAUI

(Add cols. a to c)

9. Diesel Oil

10. Alternative Fuel

11. Naphtha

DECLARATION

I declare, under the penalties set forth in section 231-36, HRS, that this is a true, correct, and complete return, prepared in accordance with the provisions of chapter 243,

HRS, the Fuel Tax Law, and chapter 18-243, HAR.

_____________________________

___________________________ ____________

(

)

Daytime Phone Number

Signature

Type or Print Name and Title

Date

FORM M-22