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) Seller’s Full Address

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Seller’s Occupation 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 copper 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 )
) SS.
COUNTY OF MAUI )

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 he 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