Form A 6 – Fill Out and Use This PDF

FORM A-6

STATE OF HAWAII — DEPARTMENT OF TAXATION

FOR OFFICE USE ONLY

(REV. 10/2019)

TAX CLEARANCE APPLICATION

Form A-6 can be filed electronically OR for all state, city, or county government

BUSINESS START DATE IN HAWAII

contracts, may be obtained through Hawaii Compliance Express. See Instructions.

IF APPLICABLE

(NOTE: References to “married” and “spouse” are also references to

/

/

“in a civil union” and “civil union partner,” respectively.)

HAWAII RETURNS FILED

1. APPLICANT INFORMATION:

(PLEASE TYPE OR PRINT CLEARLY)

IF APPLICABLE

20______

20______

20______

Applicant’s Name

________

________

________

Address

City/State/Postal/Zip Code

STATE APPROVAL STAMP

DBA/Trade Name

(State Approval QR Code)

2. TAX IDENTIFICATION NUMBER:

HAWAII TAX I.D. #

FEDERAL EMPLOYER I.D. # (FEIN)

-

SOCIAL SECURITY # (SSN)

-

-

You may scan the QR code to authenticate this tax clearance

3. APPLICANT IS A/AN: (Check only ONE box)

IRS APPROVAL STAMP

 CORPORATION

 S CORPORATION

 TAX EXEMPT ORGANIZATION

(City, County, or State Government Contract)

 INDIVIDUAL

 PARTNERSHIP

 ESTATE

 TRUST

4. THE TAX CLEARANCE IS REQUIRED FOR: (MUST check at least ONE box)

 CITY, COUNTY, OR STATE GOVERNMENT CONTRACT IN HAWAII *

 LIQUOR LICENSE

 REAL ESTATE LICENSE

 CONTRACTOR LICENSE

 FINANCIAL CLOSING

 PROGRESS PAYMENT

 PERSONAL

 HAWAII STATE RESIDENCY

 FEDERAL CONTRACT

 SUBCONTRACT

 LOAN

 OTHER

(

)

(

)

SIGNATURE

DATE

TELEPHONE

FAX

PRINT NAME

PRINT TITLE: Corporate Officer, General Partner or Member, Individual (Sole Proprietor), Trustee, Executor

A6_I 2019B 01 VID01

ID NO 01

APPLICANT’S NAME FROM PAGE 1

6.

CITY, COUNTY, OR STATE GOVERNMENT CONTRACT:

 Bid/Entering Into or Ongoing Contract

 Completion/Final Payment

For completion/final payment of contract, provide the name, agency, and telephone number of the contact person at the State or County Agency.

Name:

Agency:

Telephone Number:

7.

LIQUOR LICENSING:

 Initial

 Renewal

 Transfer-Seller

 Transfer-Buyer

 Special Event

8.

CONTRACTOR LICENSING:

 Initial

 Renewal

10. ACCOUNTING PERIOD:

 Calendar year

 Fiscal year ending (MM/DD)

11. TAX EXEMPT ORGANIZATION:

A) Provide the Internal Revenue Code section that applies to your exemption (e.g., 501(c)(3)):

B) Does your organization file federal Form 990-T, Exempt Organization Business Income Tax Return?

 YES

 NO

federal Form 990-EZ, Short Form Return of Organization Exempt From Income Tax?

 YES

 NO

If “YES,” your organization is required to obtain a general excise tax license. Go to line 13.

If “NO,” go to line 11D.

D) Does your organization have fundraising income?

 YES

 NO

If “YES,” your organization is required to obtain a general excise tax license.

12. INDIVIDUAL: Spouse’s Name

SSN

13. IF YOU DO NOT HAVE A GENERAL EXCISE TAX LICENSE AND REQUIRE A TAX CLEARANCE:

A) Description of your firm’s business

B) Has your firm had any business income in Hawaii?

 YES

 NO

C) Has your firm had an office, inventory, property, employees, or other representatives in the State of Hawaii?

 YES

 NO

D) Has your firm provided any services within the State of Hawaii (e.g., servicing computers, training sessions, etc.)?

 YES

 NO

used in Hawaii.

 YES

 NO

Note: If you answer “Yes” to any of the above questions, you are required to apply for a general excise tax license.

State Department of Taxation

Internal Revenue Service

Taxpayer Services Branch

W&I Field Assistance

P.O. Box 259

300 Ala Moana Blvd., #1-128

Honolulu, HI 96809-0259

Honolulu, HI 96850

Telephone No.: 808-587-4242

(By appointment only. To make an

Toll Free: 1-800-222-3229

appointment, please call 844-545-5640.)

Fax No.: 808-587-1488

or

Automated phone messaging: 808-566-2748

830 Punchbowl Street RM 124

Fax No.: 855-877-0789

Honolulu, HI 96813-5094