Form Cdi Fs-003 - Title Insurance Tax Return - 2011 Page 2
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3State of California
Department of Insurance
TITLE INSURANCE TAX RETURN
CDI FS-003 (REV 9/2011)
2011
FOR CALENDAR YEAR
TAX DUE DATE APRIL 1, 2012
Name of Insurer
Fed Tax I.D. No.
CA Perm No.
NAIC No.
DECLARATION OF INSURER
This return must be signed by an Executive Officer, United States Manager, or Manager residing within
California, pursuant to California Revenue and Taxation Code Section 12303.
I,
,
Type or print Name
Type or print Title
of
,
Type or print Name of Company
hereby declare under penalty of perjury that this return (including the accompanying schedules and
statements) has been examined by me and is a true, correct, and complete return.
Signature
Date
City
State
SPACE FOR NOTARY
State of _______________________________
County of _____________________________________________
On this _____________ day of __________________20 _______ before me personally appeared ___________________________
who is personally known to me as the __________________________ of ______________________________________________
and who has taken an oath that the foregoing is true, correct and complete.
Seal:
__________________________________
Print or type Name and sign above the line
Contact person for this tax return:
Name:
Title:
Type or Print
Address if different from Page 1
Phone:
Mailing Address
Fax number:
City, State, Zip
E-Mail
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