Form M-19 - Cigarette And Tobacco Products Monthly Tax Return Page 3
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4FORM M-19 (REV. 2011)
PAGE 3
Name
Cigarette Tax and Tobacco Tax License Number
Month Ending
__ __ / __ __
(MM/YY)
PART II - REFUND OF CIGARETTE TAX PAID WITH CIGARETTE TAX STAMPS
MCF113
SCHEDULE 1 — CIGARETTES SHIPPED OUTSIDE OF THE STATE FOR SALE OR USE OUTSIDE THE STATE
Attach copy of Form M-104, Export Exemption Certificate for Cigarette and Tobacco Taxes
Number of Cigarettes
Number of Packages
Number of Cigarette Tax
Value
Amount of Refund
per Package
Shipped Outside Hawaii
Stamps on Package
(C) x $3.20
(B) x (D)
(A)
(B)
(C)
(D)
(E)
20
1
$3.20
$
Other than 20
$
$
1. Refund (Add all amounts in column (E))
$
SCHEDULE 2 — CIGARETTES WHICH BECAME THE SUBJECT OF A CASUALTY LOSS
Attach copy of claim of loss to insurance company for inventory lost or destroyed
Number of Cigarettes
Number of Packages
Number of Cigarette Tax
Value
Amount of Refund
per Package
Subject to a
Stamps on Package
(C) x $3.20
(B) x (D)
Casualty Loss
(A)
(B)
(C)
(D)
(E)
20
1
$3.20
$
Other than 20
$
$
2. Refund (Add all amounts in column (E))
$
SCHEDULE 3 — STALE CIGARETTES RETURNED TO MANUFACTURER
Attach copy of certification from manufacturer for return of stale cigarettes
TABLE 1: Use Table 1 for cigarette packages with yellow or red stamps which were distributed (as defined in sec. 245-1, HRS) after June 30, 2010, and prior to July 1, 2011. See instructions.
Number of Cigarettes
Serial Number of
Number of Packages
Number of Cigarette
Value
Amount of Refund
per Package
Stamps
Returned to the
Tax Stamps
(D) x $3.00
(C) x (E)
Manufacturer
on Package
(A)
(B)
(C)
(D)
(E)
(F)
20
1
$3.00
$
Other than 20
$
$
3a. Refund (Add all amounts in Column (F))
$
TABLE 2: Use Table 2 for cigarette packages with light gray or yellow stamps which were distributed (as defined in section 245-1, HRS) after June 30, 2011. See instructions.
Number of Cigarettes
Serial Number of
Number of Packages
Number of Cigarette
Value
Amount of Refund
per Package
Stamps
Returned to the
Tax Stamps
(D) x $3.20
(C) x (E)
Manufacturer
on Package
(A)
(B)
(C)
(D)
(E)
(F)
20
1
$3.20
$
Other than 20
$
$
3b. Refund (Add all amounts in Column (F))
$
SCHEDULE 4 — OVERPAYMENT OF TAX ON CIGARETTE PACKAGES CONTAINING MORE THAN 20 CIGARETTES
Number of Cigarettes
Tax on Package
Number of Cigarette Tax
Value
Amount of Refund
per Package
of Cigarettes
Stamps on Package
(C) x $3.20
[(D) - (B)] x Number of Cigarette
(A) x $.16
Packages
(A)
(B)
(C)
(D)
(E)
$
$
$
$
$
$
4. Refund (Add all amounts in column (E))
$
Schedule 5 Continued on Page 4
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