Fillable California Form 570 - Nonadmitted Insurance Tax Return

TAXABLE YEAR

CALIFORNIA FORM

2015

570

Nonadmitted Insurance Tax Return

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Amended

Select calendar quarter during which the taxable insurance contract(s) took effect or was renewed.

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September 30

Period ending:

March 31

June 30

December 31

Part I Policyholder

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Business name

SSN or ITIN

FEIN

CA Corp no.

CA SOS file no.

Initial

First name

Last name

DBA (if applicable)

Address (apt./ste., room, PO Box, or PMB no.)

City (If you have a foreign address, see instructions.)

State

ZIP Code

Telephone

(

)

Part II Tax Computation (Do not use negative numbers. See instructions.)

1 Gross premiums paid or to be paid on risks located entirely within California, and California is your principal place of

business or your principal residence. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

2 Gross premiums paid or to be paid by California home state insured, including policies with risks outside California . . . . . .2

3 Total taxable premiums. Add line 1 and line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

4 Total tax. Multiply line 3 by 3% (.03). (There is no stamping fee.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

5 3% of returned premiums previously taxed. Attach copies of all contracts. See instructions.

Total premiums returned $

Quarter/year taxed

Policy No.

. . . . 5

m m / y

6 Overpayments from prior quarters. Quarter/year

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

m m / y

7 Prepayments. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

8 Total premiums returned, overpayments, or prepayments. Add line 5 through line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

9 Balance. Subtract line 8 from line 4. If the amount on line 8 is more than the amount on line 4, see instructions . . . . . . . . .9

10 Penalty for late payment of tax. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

11 Interest on late payment. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

12 Payment due. Add line 9 through line 11. If the result is positive, enter here. Make a check or money order

payable to the “Franchise Tax Board”. See instructions. Check the box if paying via EFT. . . . . . . . . . . . . . . . . EFT

. . . . 12

13 Overpayment. Add line 9 through line 11. If result is negative, enter here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

14 Overpayment to be applied to the next quarter. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

15 Refund. Subtract line 14 from line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

If you are an agent or broker with a valid power of attorney authorizing you to file this return on behalf of the insured, enter the following information:

Business Name

Contact Person’s Name

Business Address

Contact Person’s Phone

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.

Print or type elected officer or authorized person’s name

Sign

Here

Elected officer or authorized person’s signature

Date

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Print or type preparer’s name

Telephone

Check if

self-employed

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(