FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMPClear Form
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy A - Attach to Form N-35

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01           ATTACH TO THE FRONT OF FORM N-35 WHERE INDICATED
                                                                                                FORM N-4
N4_I 2020A 01 VID01
                                                                   CUT HERE                                                               

FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMP
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy A - Attach to Form N-35

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01           ATTACH TO THE FRONT OF FORM N-35 WHERE INDICATED
                                                                                                FORM N-4
N4_I 2020A 01 VID01

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FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMP
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy B - For your records

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01
                                                                                                FORM N-4
N4_I 2020A 01 VID01
                                                                   CUT HERE                                                               

FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMP
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy B - For your records

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01
                                                                                                FORM N-4
N4_I 2020A 01 VID01

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 
file 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 (SSN), if an individual, or Federal Employer 
     Identification 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 
file 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 (SSN), if an individual, or Federal Employer 
     Identification 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.

FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMP
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy C - For Shareholder’s records

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01           Do NOT submit this copy with your Form N-15.  Keep for your files
                                                                                                FORM N-4
N4_I 2020A 01 VID01
                                                                   CUT HERE                                                               

FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMP
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy C - For Shareholder’s records

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01           Do NOT submit this copy with your Form N-15.  Keep for your files
                                                                                                FORM N-4
N4_I 2020A 01 VID01

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 
file 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 3 — Amount of Hawaii Tax Withheld — 
        Include the amount shown in this box on Form N-15, line 54 or Form N-40 Schedule G, line 6(b). 

Do not attach this copy of Form N-4 to your Hawaii income tax return.  This copy is for your records.

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 
file 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 3 — Amount of Hawaii Tax Withheld — 
        Include the amount shown in this box on Form N-15, line 54 or Form N-40 Schedule G, line 6(b). 

Do not attach this copy of Form N-4 to your Hawaii income tax return.  This copy is for your records.

FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMP
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy D - Filed with Shareholder’s Form N-15 or N-40

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01                  ATTACH this copy to your Form N-15 or N-40
                                                                                                FORM N-4
N4_I 2020A 01 VID01
                                                                   CUT HERE                                                               

FORM                      STATE OF HAWAII—DEPARTMENT OF TAXATION              THIS SPACE FOR DATE RECEIVED STAMP
                          STATEMENT OF WITHHOLDING 
N-4                       FOR A NONRESIDENT SHAREHOLDER 
(REV. 2020)
                          OF AN S CORPORATION 
                                                           
                          20__
                          S Corporation’s Tax Year Ending            ,   20   
                                                                        
                          Copy D - Filed with Shareholder’s Form N-15 or N-40

 1.  S Corporation’s Name and Mailing Address                • 2. Shareholder’s SSN or FEIN 
                                                               
                                                             • 3. Amount of Hawaii Tax Withheld 
                                                               
 4.  S Corporation’s FEIN                                • 5. Shareholder’s Name and Mailing Address 
                                                             
 6.  Shareholder’s Share of S Corporation’s  
  Hawaii Income

ID NO 01                  ATTACH this copy to your Form N-15 or N-40
                                                                                                FORM N-4
N4_I 2020A 01 VID01