Criminal Justice Division

Identify Reporting Period:

Note: Do not submit reports until the reporting month has concluded.

Reporting Year*

Reporting Month*

Are you submitting a new or an amended form?*

New Form

Amended Form

If amended, please describe the amendments below*

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*

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*

Alternate Email

Phone*

Alternate Phone

TEU 10 Licensee Report Details

1) Did this licensee affix cigarette tax stamps to the bottom of cigarette packages during the reporting period?*

Yes

No

2) Did this licensee affix stamps to cigarette packages produced by a Non-Participating Manufacturer (NPM)?*

Yes

No

Note: Please be advised that the stamping or sale of cigarettes or RYO products is prohibited unless the cigarette or RYO product is listed in the Hawaii Tobacco Directory (Directory) pursuant to HRS sections 486P-5 and 486P-6. See also HRS §245-22.5. The directory is available at http://ag.hawaii.gov/cjd/tobacco-enforcement-unit

You’ve indicated that cigarette tax stamps were affixed to cigarette packages during the reporting period.

Upload TEU10: Monthly Report by Licensed Cigarette Stampers or attach supporting documentation here.

File*

Max. file size: 100 MB.

Please upload only .xls, .xlsx, or .pdf document types. Please note Microsoft Excel is preferred

Due to the attachment size limitation, it may be necessary to submit this form more than once. Please check here if you are submitting multiple forms for the same reporting period:

More than one form is submitted for this reporting period

You’ve indicated that no cigarette tax stamps were affixed to cigarette packages during the reporting period.

If this is incorrect, please return to the previous page. Otherwise, please proceed.

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

TEU 10 Form

TEU 10 Form

Criminal Justice Division

Administrator of Criminal Justice Division

About Us

Policies