Clear Form

FORM G-19                                 STATE OF HAWAII — DEPARTMENT OF TAXATION
(REV. 2016)
                                          RESALE CERTIFICATE 
                                          SPECIAL FORM 
                                          (For use singly or with General Form 2)

To  
                       Name of Seller

                       Address of Seller                                           Date of this Certificate

    City               State              Postal/ZIP Code

    The undersigned hereby certifies the following under penalties set forth in section 231-36, Hawaii Revised Statutes 
(HRS), as Purchaser or as an authorized agent or representative of the named Purchaser, pursuant to section 237-13(2)(F), 
HRS, and Hawaii Administrative Rules (HAR), relating to resale certificates and sales at wholesale:
    That the Purchaser is the holder of Hawaii Tax Identification No. GE __ __ __ -__ __ __ -__ __ __ __ - __ __ under the 
General Excise Tax Law and subject to the taxing jurisdiction of the State.
    That the Purchaser is engaged in the contracting business or is subject to taxation the same as if so engaged.
    That until this Certificate is revoked by notice in writing, it shall apply to all sales of materials or commodities which the 
Purchaser shall purchase from the Seller named above in connection with that certain work or project identified below, except 
those orders as to which the Purchaser shall specify by notice in writing that this Certificate does not apply. The work or project is: 

    Brief description

    Location, described by street address

    Tax Map Key Number                                    Building Permit Number

    That all the materials and commodities to which this Certificate applies will be incorporated into the finished work or 
project identified above and will remain in such finished work or project in such form as to be perceptible to the senses.
    That the work or project identified above is one in which the Purchaser is engaged as a part of his or her contracting 
business, or one which renders the Purchaser liable to the same tax as if engaged in the business of contracting, as set forth 
in section 237-4(a)(4), HRS, and section 18-237-4(a)(4), HAR, and that it is not a federal cost-plus contract governed by the 
election provided for by section 237-13(3)(C), HRS.
    That the Purchaser, pursuant to section 237-13(2)(F)(i), HRS and section 18-237-13-02(d)(2)(B), HAR, 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 (Owner, Partner or Member, Officer, or Duly Authorized Agent)Date

           Seller should retain this Certificate for Seller’s files. Do NOT send to the Department of Taxation.

                                                                                                                             FORM G-19