FORM G-49
(Rev. 2019)
Page 2 of 2
Column a Column b Column c
BUSINESS VALUES, GROSS PROCEEDS EXEMPTIONS/DEDUCTIONS TAXABLE INCOME
ACTIVITIES OR GROSS INCOME (Attach Schedule GE) (Column a minus Column b)
PART III - INSURANCE COMMISSIONS @ .15% (.0015)
Enter this amount on line 26, Column c
18
PART IV - COUNTY SURCHARGE — Enter the amounts from Part II, line 17, Column c attributable to each county. Multiply Column c by
the applicable county rate(s) and enter the total of the result(s) on Part VI, line 27, Column e.
19. Oahu (rate = .005) 19
20. Maui 20
21. Hawaii (rate = .005) 21
22. Kauai (rate = .005) 22
18. Insurance
Commissions
PART VI - TOTAL RETURN AND RECONCILIATION
TAXABLE INCOME TAX RATE TOTAL TAX
Column c Column d Column e = Column c X Column d
24. Enter the amount from Part I, line 7 ................... x .005 24.
25. Enter the amount from Part II, line 17 ................ x .04 25.
26. Enter the amount from Part III line 18, Column c ............. x .0015 26.
27. COUNTY SURCHARGE TAX. See Instructions for Part IV. Multi district complete Form G-75 ....27.
28. TOTAL TAXES DUE. Add column e of lines 24 through 27 and enter result here (but not less than zero).
If you did not have any activity for the period, enter “0.00” here ............................................... 28.
29. Amounts Assessed During the Period.......................
PENALTY $
INTEREST $
29.
30. TOTAL AMOUNT. Add lines 28 and 29. ...................................................................................30.
31. TOTAL PAYMENTS MADE LESS ANY REFUNDS RECEIVED FOR THE TAX YEAR ..................31.
32. CREDIT CLAIMED ON ORIGINAL ANNUAL RETURN. (For Amended Return ONLY) ................... 32.
33. NET PAYMENTS MADE. Line 31 minus line 32 ..............................................................................33.
34. CREDIT TO BE REFUNDED. Line 33 minus line 30 ....................................................................... 34.
35. ADDITIONAL TAXES DUE. Line 30 minus line 33 ..........................................................................35.
36. FOR LATE FILING ONLY
PENALTY $
INTEREST $
36.
37. TOTAL AMOUNT DUE AND PAYABLE (Add lines 35 and 36) ........................................................37.
38. PLEASE ENTER THE AMOUNT OF YOUR PAYMENT. If you are NOT submitting a
payment with this return, please enter “0.00” here. ......................................................................... 38.
39. GRAND TOTAL OF EXEMPTIONS/DEDUCTIONS CLAIMED. (Attach Schedule GE) If Schedule
GE is not attached, exemptions/deductions claimed will be disallowed. ..........................................39.
Form G-49
(Rev. 2019) 16
PART V — SCHEDULE OF ASSIGNMENT OF TAXES BY DISTRICT (ALL taxpayers MUST complete this Part and may be subject to a 10% penalty for noncompliance.)
Place an X in the box of the taxation district in which you have conducted business. IF you did business in MORE THAN ONE district, place an X in the box for “MULTI” and attach Form G-75.
23. Oahu Maui Hawaii Kauai MULTI
23
Name:___________________________________________________
Hawaii Tax I.D. No.
Last 4 digits of your FEIN or SSN
TAX YEAR ENDING
G49_F 2019A 02 VID99
ID NO 99
(mm-dd-yy)
If negative number, place a minus sign (-)
If negative number, place a minus sign (-)
If negative number, place a minus sign (-)
If negative number, place a minus sign (-)
If negative number, place a minus sign (-)
To enter a value in line 32 mark the "Amended" checkbox on page 1