PACT Act Reporting Form

Identify Reporting Period:

Reporting Year*

Reporting Month*

Identify your business:

Name of Business (Master Name) or Seller*

Trade Name (If any)

Federal Tax Identification (FEIN)*

State Identification Number

Hawaii Tobacco Tax License Number (if applicable)

DOTAX Business License Search: https://hitax.hawaii.gov/

Main Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Website

Email*

Phone*

Reporting Options:*

No sales into Hawaii/no interstate commerce.

Sales into Hawaii of cigarettes and roll-your-own (RYO).

Sales into Hawaii of other tobacco products (OTP) (including smokeless tobacco and electronic nicotine delivery systems (ENDS)).

You have indicated no sales into Hawaii/no interstate commerce.

If this is correct, please proceed to the next page. If this is not, then please return to the previous page.

You’ve indicated sales into Hawaii of cigarettes and roll-your-own (RYO).

If this is incorrect, please return to previous page.

Upload Part 3 Report: Memorandum of Shipments in Interstate Commerce of Cigarettes and RYO (“Link to Part 3 Report excel sheet”) or upload invoices of shipments.

Upload Part 3 Report or Invoices of Shipments*

Max. file size: 25 MB.

You’ve indicated sales into Hawaii of other tobacco products (OTP) (including smokeless tobacco and electronic nicotine delivery systems (ENDS)).

If this is incorrect, please return to previous page.

Submit Part 4 Report: Memorandum of Shipments in Interstate Commerce of Other Tobacco Products (“Link to Part 4 Report excel sheet”) or upload invoices of shipments.

Upload Part 4 Report or Invoices of Shipments*

Max. file size: 25 MB.

Comments/Notes

Please check the following:*

I declare under penalty of law that the foregoing information is true and correct to the best of my knowledge and belief.

Authorized Representative*

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Enter Email Confirm Email

(copy of submission will be sent to this address)

Additional Contact Information

Criminal Justice Division