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FORM TA -1 STATE OF HAWAII — DEPARTMENT OF TAXATION DO NOT WRITE IN THIS AREA 20 <br />(Rev. 2018) <br />p p TRANSIENT ACCOMMODATIONS <br />TAX RETURN <br />❑' : For periods beginning AFTER December 31, 2017 <br />ID NO Ol <br />Place an "X" in this box ONLY if this is an AMENDED return <br />PERIOD ENDING HAWAII TAX 1. D. NO. TA <br />NAME: Last 4 digits of your FEIN or SSN <br />X DISTRICT <br />z� <br />LU u> <br />Z <br />Z 2 1. OAHU <br />�a <br />�c <br />10 <br />2. MAUI, MOLOKAI, LANAI <br />CL v 3. HAWAII <br />a <br />Column a Column b Column c <br />GROSS RENTAL OR EXEMPTIONS/DEDUCTIONS TAXABLE PROCEEDS <br />GROSS RENTAL PROCEEDS (Explain on Reverse Side) (Column a minus Column b) <br />1 <br />Taxable gross 2 <br />rental proceeds <br />3 <br />subject to HCTAT <br />4. KAUAI 4 <br />9. TOTAL AMOUNT TAXABLE. Add Column c of lines 1 through 4 and lines 5 <br />FZ through 8. Enter result here (but not less than zero)................................................................................9. <br />Ia <br />a 10. <br />L 11. <br />Tax Rate 10. <br />TOTAL TAXES DUE. Multiply line 9 by line 10 and enter the result here. If you did <br />not have any activity for the period, enter "0.00" here.......................................................11. <br />F 12. Amounts Assessed During the Period... PENALTY <br />Z(ForAmended Return ONLY) 12 <br />INTEREST <br />C0 <br />0 13. TOTAL AMOUNT. Add lines 11 and 12. (ForAmended Return ONLY) ........................... 13. <br />a <br />14. TOTAL PAYMENTS MADE FOR THE PERIOD (ForAmended Return ONLY) ........................ 14. <br />15. CREDIT TO BE REFUNDED. Line 14 minus line 13 ForAmended Return ONLY 15. <br />16. ADDITIONAL TAXES DUE. Line 13 minus line 14 (ForAmended Return ONLY) .................. 16. <br />x0.1025 <br />DECLARATION - I declare, under the penalties set forth in section 231-36, HRS, that this return (including any accompanying schedules or statements) has been <br />examined by me and, to the best of my knowledge and belief, is a true, correct, and complete return, made in good faith for the tax period stated, pursuant to the <br />Transient Accommodations Tax Laws, and the rules issued thereunder. <br />IN THE CASE OF A CORPORATION OR PARTNERSHIP, THIS RETURN MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT. <br />TA1_I2018A01VID01 Continued on page 2 — Parts V & VI MUST be completed Form TA -1 <br />(Rev. 2018) 2O <br />TOTAL FAIR MARKET RENTAL VALUE <br />LU <br />cc <br />=H 5. <br />OAHU DISTRICT......................................................................................................................5. <br />LU <br />wv <br />— Z 6. <br />a <br />MAUI, MOLOKAI, LANAI DISTRICT ....................................... <br />Timeshares -fair <br />6. <br />market rental value <br />—7-> <br />HV 7. <br />HAWAII DISTRICT.................................................................. <br />subject to HCTAT <br />Qo <br />a <br />8. <br />KAUAI DISTRICT......................................................................................................................8. <br />9. TOTAL AMOUNT TAXABLE. Add Column c of lines 1 through 4 and lines 5 <br />FZ through 8. Enter result here (but not less than zero)................................................................................9. <br />Ia <br />a 10. <br />L 11. <br />Tax Rate 10. <br />TOTAL TAXES DUE. Multiply line 9 by line 10 and enter the result here. If you did <br />not have any activity for the period, enter "0.00" here.......................................................11. <br />F 12. Amounts Assessed During the Period... PENALTY <br />Z(ForAmended Return ONLY) 12 <br />INTEREST <br />C0 <br />0 13. TOTAL AMOUNT. Add lines 11 and 12. (ForAmended Return ONLY) ........................... 13. <br />a <br />14. TOTAL PAYMENTS MADE FOR THE PERIOD (ForAmended Return ONLY) ........................ 14. <br />15. CREDIT TO BE REFUNDED. Line 14 minus line 13 ForAmended Return ONLY 15. <br />16. ADDITIONAL TAXES DUE. Line 13 minus line 14 (ForAmended Return ONLY) .................. 16. <br />x0.1025 <br />DECLARATION - I declare, under the penalties set forth in section 231-36, HRS, that this return (including any accompanying schedules or statements) has been <br />examined by me and, to the best of my knowledge and belief, is a true, correct, and complete return, made in good faith for the tax period stated, pursuant to the <br />Transient Accommodations Tax Laws, and the rules issued thereunder. <br />IN THE CASE OF A CORPORATION OR PARTNERSHIP, THIS RETURN MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT. <br />TA1_I2018A01VID01 Continued on page 2 — Parts V & VI MUST be completed Form TA -1 <br />(Rev. 2018) 2O <br />