This form is used to report Hawaii income taxes withheld from a shareholder of an S corporation who is a
nonresident of Hawaii and who has not provided the S corporation with a signed agreement (Schedule NS) to
fi le a return, make timely payment of all Hawaii taxes imposed with respect to the shareholder’s share of the S
corporation’s Hawaii income, and to be subject to personal jurisdiction in Hawaii for purposes of the collection
of unpaid income tax and related interest and penalties.
Box 1 — Enter the S corporation’s name and mailing address.
Box 2 — Enter the shareholder’s social security number, if an individual, or Federal Employer Identifi cation
Number (FEIN).
Box 3 — Enter the amount of Hawaii tax withheld on the shareholder’s share of the corporation’s Hawaii
income.
Box 4 — Enter the S corporation’s FEIN.
Box 5 — Enter the shareholder’s name and mailing address.
Box 6 — Enter the shareholder’s share of the S corporation’s Hawaii income.
This form is used to report Hawaii income taxes withheld from a shareholder of an S corporation who is a
nonresident of Hawaii and who has not provided the S corporation with a signed agreement (Schedule NS) to
fi le a return, make timely payment of all Hawaii taxes imposed with respect to the shareholder’s share of the S
corporation’s Hawaii income, and to be subject to personal jurisdiction in Hawaii for purposes of the collection
of unpaid income tax and related interest and penalties.
Box 1 — Enter the S corporation’s name and mailing address.
Box 2 — Enter the shareholder’s social security number, if an individual, or Federal Employer Identifi cation
Number (FEIN).
Box 3 — Enter the amount of Hawaii tax withheld on the shareholder’s share of the corporation’s Hawaii
income.
Box 4 — Enter the S corporation’s FEIN.
Box 5 — Enter the shareholder’s name and mailing address.
Box 6 — Enter the shareholder’s share of the S corporation’s Hawaii income.