HTAT-3 Bulk Filers Authorization Form

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FORM (202) FORM (202) TAXPAYER INFORMATION Taxpayer’s Name Hawaii Identification Number Trade Name or Doing Business as (DBA) Name FEIN/SSN C/O Contact Name Mailing Address (Number and Street)Contact Daytime Telephone Number ( ) City, State, and Postal/ZIP Code Contact Fax Number ( ) Contact E-mail Address REPORTING AGENT INFORMATION Reporting Agent’s Name (Name of company or business) Authorized Representative’s Name Reporting Agent’s Mailing Address (Number and Street) Representative’s Hawaii VPID Number City, State, and Postal/Zip Code Representative’s Daytime Telephone Number ( ) AUTHORIZATION TO SIGN AND FILE TAX RETURNS AND TO MAKE PAYMENTS The Reporting Agent and the above named Authorized Representative are authorized to sign and file the below indicated tax returns and to make payments in connection with the below indicated tax returns: , Periodic Tax Return ....................................for the period beginning , ...................for the period beginning AUTHORIZATION AGREEMENT Please read the following Authorization Agreement: The above named taxpayer understands the following responsibilities: •The above named taxpayer is responsible for the actions of the Reporting Agent and the above named Authorized Representative in connection with (a) the above indicated tax returns filed and (b) the related payments made; •All tax returns must be timely filed and all taxes must be timely paid; and •All filed tax returns are true, correct, and complete by the above named taxpayer. The failure of the Reporting Agent and the above named Authorized Representative to comply with tax laws shall not absolve the above named taxpayer of its responsibilities to comply with tax laws. The Reporting Agent and the above named Authorized Representative are authorized to sign and file the above indicated tax returns and to make payments in connection with the above indicated tax returns for the above named taxpayer. This authorization applies to the above indicated tax returns and related payments beginning with the indicated tax period and remains in effect until the above named taxpayer notifies the Reporting Agent. I authorize the , , to disclose otherwise confidential tax information to the Reporting Agent and the above named Authorized Representative in connection with the transmission of the above indicated tax returns and related payments. I hereby certify under the penalties of perjury that I have the authority to authorize, on behalf of the above named taxpayer, the Reporting Agent and the above named Authorized Representative (a) to sign and file the above indicated tax returns, (b) to make payments in connection with the above indicated tax returns, and (c) to receive confidential information in connection with the transmission of the above indicated tax returns and related payments. Signature Date Print Name Title PART I PART II PART III PART IV