TAXABLE YEAR
CALIFORNIA FORM
2014
570
Nonadmitted Insurance Tax Return
Amended
Select calendar quarter during which the taxable insurance contract(s) took effect or was renewed.
September 30
Period ending:
March 31
June 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
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
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
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.
___________________________________________________________________________
Sign
Here
Print or type elected officer or authorized person’s name
_____________________________
___________________________________________________________________________
Date
Elected officer or authorized person’s signature
May the FTB discuss this return with the preparer shown below? See instructions . . . . .
Yes
No
Check if
Telephone
___________________________________________________________________
self-employed
-
Print or type preparer’s name
(
)
Date
___________________________________________________________________
PTIN
Paid
Preparer’s signature
Preparer’s
Use Only
FEIN
Business name (or yours, if
-
self-employed) and address
Form 570
2013 Side 1
3681143
C1
For Privacy Notice, get FTB 1131 ENG/SP.