Fillable California Form 570 - Nonadmitted Insurance Tax Return

TAXABLE YEAR

CALIFORNIA FORM

2013

570

Nonadmitted Insurance Tax Return

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Amended

Select calendar quarter during which the taxable insurance contract(s) took effect or was renewed.

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September 30

Period ending:

March 31

June 30

December 31

Part I Policyholder

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Business name

SSN or ITIN

FEIN

CA Corp. no.

CA 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

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

Payment due. Add line 9 through line 11. If the result is positive, enter here. Make a check or money order

. . . . 12

payable to the “Franchise Tax Board”. See instructions. Check the box if paying via EFT . . . . . . . . . . . . . . . . . . . . . . EFT

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

Check entity type:

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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

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May the FTB discuss this return with the preparer shown below? See instructions . . . . .