Form 540ins - Request For Refund Of Louisiana Citizens Property Insurance Corporation Assessment - 2016

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R-540INS (6/16)
FILING PERIOD
Individual
Request for Refund of Louisiana
2016
Citizens Property Insurance
Income Tax
Corporation Assessment
Your first name
MI Last name
Suffix
Your Social
➜
Security Number
If joint return, spouse’s name
MI Last name
Suffix
Spouse’s Social
➜
Security Number
Current home address (number and street including apartment number or rural route)
➜
City, town, or APO
State
ZIP
For amended return, mark this box.
➜
Louisiana Revised Statute 47:6025 allows a refundable tax credit equal to 25 percent of the Louisiana Citizens Property Insurance
assessment that you paid between January 1, 2016, and December 31, 2016 as a part of your homeowner’s insurance premium. You
may claim the Louisiana Citizens Property Insurance Corporation assessment refund on this form or on your individual income tax return,
but not on both forms. Claiming the refund on both forms will delay your individual income tax return for review.
One Property
If you paid the Louisiana Citizens Property Insurance Corporation assessment for only one property, list the property’s address, the insurance
company’s name, and the insurance policy number in the boxes below. Enter the amount of your paid assessment below on Line 1.
Address of Property
Insurance Company
Policy Number
More Than One Property
If you paid the Louisiana Citizens Property Insurance Corporation assessment for more than one property, complete the Supplement
Schedule for Refund of Louisiana Citizens Property Assessment, Form R-INS Supplement, and attach it to this return. Enter the total
amount of the assessments paid for all properties listed on the Supplement Schedules on Line 1 below.
YOU MUST ATTACH A COPY OF YOUR INSURANCE DECLARATION PAGE FOR ALL PROPERTIES.
REFUND
Calculate the Refund of Louisiana Citizens Property assessment below. Act 9 of the 2016 Second Extraordinary Session of the Louisiana
Legislature reduced the credit to 25% of the assessment paid.
1.
Enter the amount of the total assessment paid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
Multiply Line 1 by 25 percent (.25).
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I declare that I have examined this return, and to the best of my knowledge, it is true and complete. Declaration of paid preparer is based
on all available information. I also consent that the Louisiana Department of Revenue may contact my insurance company/companies to
verify the amount of the Louisiana Citizens Property Insurance Corporation assessment paid, and I further direct my insurance company/
companies to provide the Citizens Insurance Assessment information to the Louisiana Department of Revenue upon request.
Your Signature
Date
Signature of paid preparer other than taxpayer
(mm/dd/yyyy)
Spouse’s Signature (If filing jointly, both must sign.)
Date
Telephone number of paid preparer
Date
(mm/dd/yyyy)
(mm/dd/yyyy)
SPEC
CODE
Area code and daytime
telephone number
MAIL TO:
Louisiana Department of Revenue
6660
P. O. Box 3576
Baton Rouge, LA 70821-3576

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