Form 570 Advance Draft - Nonadmitted Insurance Tax Return - 2010
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1
2TAXABLE YEAR
CALIFORNIA FORM
2010
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.
First name
Initial
Last name
DBA (if applicable)
Address (number and street, PO Box, or PMB no.)
Apt. no./Ste. no.
City
State ZIP Code
Telephone number
( )
Part II Tax Computation
Premiums paid or to be paid on risks located entirely within California. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
2 a Premiums paid or to be paid on risks located within and outside of California. See instructions. . .2a_________________
b Portion of premiums on line 2a allocated to California pursuant to R&TC Section 13210(b). See instructions . . . . . . . . . 2b
00
3 Total taxable premiums. Add line 1 and line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
00
4 Total tax. Multiply line 3 by 3% (.03). (There is no stamping fee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
00
5 3% of returned premiums previously taxed. See instructions.
Total premiums returned $ _________________ Quarter/year taxed _________________ Policy No. _____________ . . . 5
00
M M Y Y Y Y
6 Credit from prior quarters. Quarter/year _________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
00
M M Y Y Y Y
7 Prepayments. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
00
8 Total credits. Add line 5 through line 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
00
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
00
0 Penalty for late payment of tax. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
00
Interest on late payment. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
2
Payment due. Add line 9 through line 11. If the result is positive, enter here. Make a check or money order
n
. . . . 2
payable to the Franchise Tax Board. See instructions. Check the box if paying via EFT . . . . . . . . . . . . . . . . . . . . . . . . EFT
00
3 Overpayment. Add line 9 through line 11. If result is negative, enter here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
00
4 Overpayment to be credited to the next quarter. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
00
5 Refund. Subtract line 14 from line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
00
Check entity type:
Corporation
Partnership
Limited Liability Company
Limited Liability Partnership
Individual
Other (specify)_________________________
Insurance Contracts – Enter the following information for each contract. If more than one contract, enter the information on Side 2.
PRINT CLEARLY
Policy Number
Name of each Nonadmitted Insurance Company
Type of Insurance Coverage
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
Business Address
Contact Person’s Name
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.
___________________________________________________________________________
Please
Sign
Print or type elected officer or authorized person’s name
Here
___________________________________________________________________________
_____________________________
Elected officer or authorized person’s signature
Date
May the FTB discuss this return with the preparer shown below(see instructions)? . . . .
Yes
No
Check if
Telephone No.
________________________________________________________________
self-employed
-
( )
Print or type preparer’s name
Date
Preparer’s SSN/PTIN
________________________________________________________________
Paid
Preparer’s signature
Preparer’s
Preparer’s FEIN
Use Only
Business name (or yours, if
-
self-employed) and address
Form 570
2009 Side
3681103
C1
For Privacy Notice, get form FTB 1131.
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