California Form 570 - Nonadmitted Insurance Tax Return
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TAXABLE YEAR
CALIFORNIA FORM
570
20
Nonadmitted Insurance Tax Return
Calendar quarter during which the taxable insurance contract(s) took effect or was renewed.
Period ending:
March 31
June 30
September 30
December 31
Name(s) of policyholder
SSN or ITIN
CA corp. no.
FEIN
Address (number and street, PO Box, Rural Route, APT no., Suite, Room, or PMB no.)
City
State ZIP Code (or equivalent)
Telephone number
( )
Check entity type:
Corporation
Partnership
Limited Liability Company
Limited Liability Partnership
Individual
Other (specify)_________________________
List the policy number, name of each nonadmitted insurance company, and the type of coverage for each contract entered into or renewed during the calendar
quarter checked above. (Attach additional sheets as needed.)
Tax Computation
1 Premiums paid or to be paid on risks located entirely within California. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 _________________________
2 a Premiums paid or to be paid on risks located within and outside of California. See instructions . .2a_________________
2 b Portion of premiums on line 2a allocated to California pursuant to R&TC Section 13210(b). See instructions . . . . . . . . . 2b _________________________
3 Total taxable premiums. Add line 1 and line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 _________________________
.03
4 Tax rate of 3% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 _________________________
5 Total tax. Multiply line 3 by line 4. (There is no stamping fee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 _________________________
6 3% of returned premiums previously taxed. See instructions.
Total premiums returned $ _________________ Quarter/year taxed ______________ Policy No. ______________ . . . . 6 _________________________
7 Credit from prior quarters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 _________________________
8 Prepayments. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 _________________________
9 Total credits. Add line 6 through line 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 _________________________
10 Balance. Subtract line 9 from line 5. If the amount on line 9 is more than the amount on line 5, see instructions. . . . . . . 10 _________________________
11 Penalty for late payment of tax. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 _________________________
12 Interest on late payment. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 _________________________
13
Total payment due. Add line 10 through line 12. If the result is positive, enter here. Make check or money
n
.
,
,
. .13
order payable to the Franchise Tax Board. If the result is negative, enter it on line 14. See instructions EFT
14 Overpayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 _________________________
15 Overpayment to be credited to the next quarter. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 _________________________
.
,
,
16 Refund. Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
If you are an agent or broker filing this return on behalf of the insured, please enter your firm’s name, address, contact person’s name, and telephone number below:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, 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 preparer has any knowledge.
Please
_______________________________________________________________________________
Sign
Print or type elected officer or authorized person’s name
Here
_______________________________________________________________________________
______________________________
Elected officer or authorized person’s signature
Date
Check if
Telephone No.
________________________________________________________________
self-employed
Print or type preparer’s name
( )
Paid
________________________________________________________________
Date
Preparer’s SSN/PTIN
-
-
Preparer’s
Preparer’s signature
Use Only
Preparer’s FEIN
Firm’s name (or yours, if
-
self-employed) and address
3681063
Form 570
2006
C1
For Privacy Notice, get form FTB 1131.
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