Form G-17 - Resale Certificate For Goods General Form 1

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FORM G-17
(REV. 2009)
STATE OF HAWAII — DEPARTMENT OF TAXATION
RESALE CERTIFICATE FOR GOODS
GENERAL FORM 1
(PLEASE PRINT OR TYPE)
To
(Name of Seller)
(Address of Seller)
(Date of this Certificate)
(City)
(State)
(Postal/ZIP Code)
The undersigned hereby certifies the following under the penalties set forth in section 231-36, Hawaii Revised Statutes
(HRS), as Purchaser or as an authorized agent or representative of the named Purchaser:
That the Purchaser is the holder of Hawaii Tax Identification No. W __ __ __ __ __ __ __ __ - __ __ under the General
Excise Tax Law and subject to the taxing jurisdiction of the State;
That the nature and character of the Purchaser’s business is:
;
That this Certificate, until revoked by notice in writing, shall apply to all purchases of tangible personal property which
the Purchaser shall purchase from the Seller named above except those orders which the Purchaser specifies by notice in
writing that this Certificate does not apply;
That all of the purchases of tangible personal property to which this Certificate applies:
are purchases for resale at retail under Chapter 237, Hawaii Revised Statutes (HRS); and/or
are purchases for resale at wholesale under Chapter 237, HRS;
That the Purchaser, pursuant to Chapter 237, HRS, as amended, and Hawaii Administrative Rules, relating to resale
certificates, sales at wholesale, and the exemption for initial wholesale sales of property imported for further resale at
wholesale, shall pay to the seller, the amount of any additional tax imposed upon the seller with respect to any transactions
covered by this certificate.
Name of Purchaser
Signature
Address of Purchaser
Print Name of Signatory
City
State
Postal/Zip Code
Title
Date
(Owner, Partner or Member, Officer, or Duly Authorized Agent)
Seller should retain this Certificate for Seller’s files. Do NOT send to the Department of Taxation.

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