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Get HI DoT G-17 2009

, the amount of any additional tax imposed upon the seller with respect to any transactions covered by this certificate. City Name of Purchaser Signature Address of Purchaser Print Name of Signatory State Postal/Zip Code Title (Owner, Partner or Member, Officer, or Duly Authorized Agent) Seller should retain this Certificate for Seller s files. Do NOT send to the Department of Taxation. Date.

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