California Form 570 - Nonadmitted Insurance Tax Return - 2016

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TAXABLE YEAR
CALIFORNIA FORM
2016
570
Nonadmitted Insurance Tax Return
Amended
Select calendar quarter during which the taxable insurance contract(s) took effect or was renewed.
Period ending:
March 31
June 30
September 30
December 31
Part I Policyholder
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
Part II Tax Computation. 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
y
y
y
6 Overpayments from prior quarters. Quarter/year
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
m m / y
y
y
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
n
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 telephone
To learn about your privacy rights, how we may use your information, and the consequences for not providing the requested information, go to ftb.ca.gov
and search for privacy notice. To request this notice by mail, call 800.852.5711.
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.
Sign
Print or type elected officer or authorized person’s name
Telephone
Here
(
)
Elected officer or authorized person’s signature
Date
Print or type preparer’s name
Telephone
Check if
self-employed
(
(
)
)
Paid
Preparer’s signature
Date
PTIN
Preparer’s
Use Only
FEIN
Business name (or yours, if
-
self-employed) and address
 
May the FTB discuss this tax return with the preparer shown above (see instructions)?. . . .
Yes
No
Form 570
2015 Side 1
3681163
C1

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