California Form 570 - Nonadmitted Insurance Tax Return - 2012
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1
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4Get instructions for 570 Form
TAXABLE YEAR
CALIFORNIA FORM
2012
570
Nonadmitted Insurance Tax Return
Amended
Select calendar quarter during which the taxable insurance contract(s) took effect or was renewed. See What’s New instructions.
Period ending:
March 31
June 30
September 30
December 31
Part I Policyholder
Business name
SSN or ITIN
FEIN
CA Corp. no.
SOS file no.
Initial
First name
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
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
2 Gross premiums paid or to be paid by California home state insured, including policies with risks outside California . . . . . 2
00
3 Total taxable premiums. Add line 1 and line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. Attach copies of all contracts. See instructions.
Total premiums returned $ _________________ Quarter/year taxed _________________ Policy No. _____________ . . . 5
00
M M Y Y Y Y
6 Overpayments from prior quarters. Quarter/year _________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
00
M M Y Y Y Y
7 Prepayments. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
00
8 Total premiums returned, overpayments, or prepayments. 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
00
payable to the “Franchise Tax Board”. See instructions. Check the box if paying via EFT . . . . . . . . . . . . . . . . . . . . . . EFT
3 Overpayment. Add line 9 through line 11. If result is negative, enter here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
00
4 Overpayment to be applied 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)_________________________
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
_____________________________
___________________________________________________________________________
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 No.
________________________________________________________________
self-employed
-
( )
Print or type preparer’s name
Date
________________________________________________________________
PTIN
Paid
Preparer’s signature
Preparer’s
FEIN
Use Only
Business name (or yours, if
-
self-employed) and address
Form 570
2011 Side
C1
3681123
For Privacy Notice, get form FTB 1131.
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