Clear Form
FORM G-61
STATE OF HAWAII — DEPARTMENT OF TAXATION
(REV. 2009)
EXPORT EXEMPTION CERTIFICATE
FOR GENERAL EXCISE AND LIQUOR TAXES
PART I — Information About the Manufacturer, Producer, Contractor, Service Provider, or Seller
Name
Type of Organization (e.g., Corporation, Partnership, Individual, etc.)
Address (number and street)
City, State, and Postal/ZIP code
Hawaii Tax I.D. Number
Liquor Permit Number (if applicable)
W __ __ __ __ __ __ __ __ - __ __
Description of the manufacturer, producer, contractor, service provider, or seller’s business
PART II — Information About the Purchaser, Consumer, or User
Name
Type of Organization (e.g., Corporation, Partnership, Individual, etc.)
Address (number and street)
City, State, and Postal/ZIP code
PART III — Tangible Personal Property/Contracting/Services/Liquor Included in Transaction
A. Description of tangible personal property/contracting/services/liquor
B. Value of tangible personal property/contracting/services/liquor or gross proceeds involved
CERTIFICATION BY MANUFACTURER, PRODUCER, CONTRACTOR, SERVICE PROVIDER, OR
SELLER AND PURCHASER, CONSUMER, OR USER
The undersigned manufacturer, producer, contractor, service provider, or seller (provider); and purchaser, consumer, or user hereby
certify, pursuant to sections 231-36, 237-29.5, 237-29.53, or 244D-4.3, Hawaii Revised Statutes (HRS), relating to export exemption and
certification:
(1) that the information provided in Parts I, II, and III above are true and correct; and
(2) that until this certificate is revoked by notice in writing by either of the parties who signed the certificate or the Department of
Taxation, it shall apply to this order or contract of sale between the manufacturer, producer, contractor, service provider, or seller;
and the purchaser, consumer, or user.
The provider certifies that he or she will remit the tax due on the sale of the tangible personal property/contracting/services/liquor, as
imposed by Chapters 237 and 244D, HRS, to the Department of Taxation if:
(1) the place of delivery of the property or liquor for which the export exemption was claimed is not outside the State;
(2) the property or liquor was not shipped or transmitted by the provider to the purchaser at a place of delivery outside the State; or
(3) the contracting or services was not resold, consumed, or used outside the State.
Manufacturer, producer, contractor, service provider, or seller signature
Purchaser, consumer, or user signature
Print name of signatory
Print name of signatory
Title
Date
Title
Date
Provider should retain this certificate for the provider’s files. DO NOT send to the Department of Taxation.
FORM G-61