Form R-620ins Request For Refund Of Louisiana Citizens Property Insurance Corporation Assessment 2006

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R-620INS (1/07)

FILING PERIOD

CORPORATE

2006

Request for Refund of Louisiana Citizens

INCOME TAX

Property Insurance Corporation Assessment

Legal Name

➔ ➔

Revenue Account

Number

Trade Name

➔ ➔

If you DO NOT have a Louisiana Revenue

Account Number, mark this box.

Address

➔ ➔

City

State

ZIP

➔ ➔

USE THIS FORM ONLY IF YOU ARE NOT REQUIRED TO FILE A LOUISIANA CORPORATE INCOME TAX RETURN.

Before You Begin

The Louisiana Legislature enacted R.S. 47:6025 which allows a refundable tax credit to reimburse a corporation that paid, before January

1, 2007, an assessment to fund the Louisiana Citizens Property Insurance Program as a part of its property insurance premium. Use this

form to claim this refund ONLY if the corporation is not required to file a Louisiana corporate income tax return for 2006. See the instructions

on the reverse side of this form for more information about corporations that are exempt from filing.

Below list the name of your insurance company and the policy number, and the amount of the assessment paid. If you have more than one

property that has been assessed, please complete Form R-INS Supplement and attach it to this return. For Line 1 below, enter the total

amount of your assessment for your first property. For Line 2 below, enter the sum of remaining assessments for all other properties you own

that incurred an assessment.

You must attach a copy or copies of your Insurance Declaration Page to this return and provide proof of payment.

Please see instructions on the other side of this form.

Physical Address of Property:

Address 1 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address 2 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City

______________________________________________________________________________ ZIP _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Insurance Company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Policy Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Amount of Assessment ➔ ➔

Total amount of additional assessment(s) paid per attached schedule(s) R-INS Supplement .............. ➔ ➔

REFUND

Add the assessment amounts on Lines 1 and 2. Print the result here. ................................................ ➔ ➔

Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my knowledge and belief, it is true,

correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which he has any knowledge. I also consent that the Louisiana

Department of Revenue may contact my insurance company/companies to verify the amount of the Louisiana Citizens Property Insurance Corporation assessment paid,

and I further direct my insurance company/companies to provide the Citizens Insurance Assessment information to the Louisiana Department of Revenue upon request.

Your signature

Date

Signature of paid preparer other than taxpayer

Spouse’s signature (If filing jointly, both must sign.)

Date

Telephone number of paid preparer

Date

(

)

Area code and daytime

MAIL TO:

telephone number