SELLER’S STATEMENT
Under penalty or perjury, the Seller certifies pursuant to Section 445-233, Hawaii Revised Statutes, the
he/she/it is the lawful owner of the scrap being sold to Purchaser, and further, that the Seller has the
lawful right to sell and dispose of the scrap.
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Seller’s Name (please print)
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Seller’s Full Address
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Seller’s Occupation
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Seller’s ID or Driver’s License Number
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Detailed description of the Copper being sold (including serial numbers and other identifying marks,
when possible, of every scrap being sold). i.e. tubing, sheets, gutter, down spouts, bars, bare wire,
insulated wire, aluminum copper/coil.
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Person or Company who sold or transferred cooper to Seller
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License Numbers of every vehicle delivering this scrap to Purchaser
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Seller’s Signature
E-H International Use Only
Date/Time _________________________
RL #____________________________
Check #___________________________________
Photo ID sent
Photo of Seller and Copper sent
STATE OF HAWAII
COUNTY OF KAUAI
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SS.
On this ________ day of ____________________, 20___, before me personally appeared_______________________,
to me known to be the person described in and who executed the foregoing instrument and acknowledged that he or she
executed the same as his or her free act and deed.
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Notary Public Signature
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Print Name of Notary Public
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Commission Expires
NOTARY CERTIFICATION
Doc. Date __________
# of Pages _____
Doc Description _________________________
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Notary Signature
Date