R-540INS (1/07)
FILING PERIOD
INDIVIDUAL
2006
Request for Refund of Louisiana Citizens
INCOME TAX
Property Insurance Corporation Assessment
Your first name
Initial Last name
Suffix
➔ ➔
➔ ➔
Your Social
Security Number
If joint return, spouse’s name
Initial Last name
Suffix
➔ ➔
➔ ➔
Spouse’s Social
Security Number
Present home address
(number and street including apartment number or rural route)
➔ ➔
City, town, or APO
State
ZIP
➔ ➔
USE THIS FORM ONLY IF YOU ARE NOT REQUIRED TO FILE A LOUISIANA INCOME TAX RETURN.
Before You Begin
The Louisiana Legislature enacted R.S. 47:6025 which allows a refundable tax credit to reimburse you if you paid, prior
to January 1, 2007, an assessment to fund the Louisiana Citizens Property Insurance Program as a part of your
homeowner’s insurance premium. You may use this form to claim this refund ONLY if you are not required to file a Louisiana
income tax return for 2006.
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.
Please see instructions on the other side of this form.
1
Address of
Property 1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Insurance Company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Policy Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
.
00
➔ ➔
Amount of Assessment
2
Total amount of additional assessment(s) paid on other properties you own.
.
➔ ➔
00
Attach Form R-INS Supplement. ................................................................................................
REFUND
.
00
➔ ➔
3
Add the assessment amounts on Lines 1 and 2. Print the result here. ............................................
I declare that I have examined this return, and to the best of my knowledge, it is true and complete. Declaration of paid preparer is based on all available information.
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
Louisiana Department of Revenue
6765
P. O. Box 3576
Baton Rouge, LA 70821-3576