California Form 570 - Nonadmitted Insurance Tax Return - 2015 Page 4
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4Additional Information
The authorization will automatically end one year
If you are an agent or broker filing this return on
from the date this tax return was filed. If the entity
behalf of the insured, the refund will be mailed to
If you have questions, contact the FTB Nonadmitted
wants to expand the paid preparer’s authorization,
you in the name of the insured if a signed Power
Insurance Desk at 916.845.7448 or call the
get form FTB 3520, Franchise Tax Board Power of
of Attorney is on file allowing the FTB to do so.
Withholding Services and Compliance telephone
Attorney Declaration. If the entity wants to revoke
Attach copies of all contracts where there was a
service at 888.792.4900.
the authorization before it ends, notify the FTB in
reduction of premiums returned or cancellation
writing or call 800.852.5711.
OR write to:
on which nonadmitted insurance tax was paid.
WITHHOLDING SERVICES AND
Line 6 – Enter the amount of overpayment you
Specific Instructions
COMPLIANCE MS F182
requested to be applied from a prior quarter
FRANCHISE TAX BOARD
that was not applied on a previously filed return.
Part I – Policyholder
PO BOX 942867
These payments may include amounts from an
SACRAMENTO CA 94267-0651
amended Form 570. Enter the calendar quarter
Enter the business or individual policyholder
and taxable year the overpayment occurred.
You can download, view, and print California tax
name, Doing Business As (DBA), if applicable,
forms and publications at ftb.ca.gov.
address, and a valid taxpayer identification
Line 7 – Enter any payments made before filing
number (TIN). The following are acceptable
the return. If the return is being filed after the due
OR to get forms by mail write to:
TINs: social security number (SSN); individual
date, see the instructions for line 10.
TAX FORMS REQUEST UNIT
taxpayer identification number (ITIN); federal
Line 9 – If the amount on line 4 is more than the
FRANCHISE TAX BOARD
employer identification number (FEIN); California
amount on line 8, subtract line 8 from line 4 and
PO BOX 307
corporation number (CA Corp no.); or California
enter the balance on line 9. You have tax due. If
RANCHO CORDOVA CA 95741-0307
Secretary of State (CA SOS) file number. Print
the amount on line 8 is more than the amount on
For all other questions unrelated to withholding
all information using CAPITAL LETTERS. If
line 4, subtract line 4 from line 8 and enter the
or to access the TTY/TDD numbers, see the
completing Form 570 by hand, enter all the
result in brackets on line 9. Your credits exceed
information below.
information requested using black or blue ink.
your tax.
Internet and Telephone Assistance
Private Mail Box (PMB) – Include the PMB in
Line 10 – If you do not pay the tax due by the
the address field. Write “PMB” first, then the box
Website:
ftb.ca.gov
due date, a penalty of 10% of the amount of tax
number. Example: 111 Main Street PMB 123.
Telephone:
800.852.5711 from within the
due will be imposed. Enter 10% of the amount of
United States
Foreign Address – Enter the information in the
tax not paid by the due date. (A penalty of 25%
916.845.6500 from outside the
following order: City, Country, Province/Region,
of the amount of tax due will be imposed when
United States
and Postal Code. Follow the country’s practice for
nonpayment or late payment is due to fraud.)
TTY/TDD:
800.822.6268 for persons with
entering the postal code. Do not abbreviate the
Line 11 – Interest will be charged on any late
hearing or speech impairments
country’s name.
payment and penalty from the due date to the
Asistencia Por Internet y Teléfono
date paid. Interest compounds daily and the
Part II – Tax Computation
interest rate is adjusted twice a year. If you do not
Sitio web:
ftb.ca.gov
Do not show net or negative amounts on line 1
include interest with your late payment or include
Teléfono:
800.852.5711 dentro de los Estados
through line 4 to account for returned premiums.
only a portion of it, the FTB will compute the
Unidos
See line 5 for returned premiums. Only use line 1
interest and send you a bill.
916.845.6500 fuera de los Estados
through line 4 to report taxable premiums paid or
Unidos
Line 12 – Enter the total amount due. Make your
to be paid during the calendar quarter.
check or money order payable to the “Franchise
TTY/TDD:
800.822.6268 para personas con
Line 1 – Enter all gross premiums paid or to be
Tax Board.” Write the calendar quarter (March,
discapacidades auditivas o del habla
paid on risks located entirely within California
June, September, or December), the applicable
for policies entered into or renewed during the
taxable year, Form 570, and your SSN, ITIN, FEIN,
calendar quarter.
CA Corp no., or CA SOS file no. on the check or
money order. Check the EFT box if you made
Line 2 – Enter all gross premiums paid or to
your payment by EFT.
be paid by California home state insured for all
policies issued by a nonadmitted insurer for
Electronic Funds Transfer (EFT) – To submit your
coverage both inside and outside of California
nonadmitted insurance tax payment using EFT,
which were entered into or renewed during the
use the following tax type code, EFT code 02020.
calendar quarter. Note: Enter only premiums for
You must use the correct EFT code to ensure
policies related to risks within the U.S.
proper credit to your FTB account.
Line 5 – Enter 3% of the premiums returned
Line 14 – Enter the amount of overpayment to be
during the calendar quarter because of
credited to your next quarter’s return.
cancellation or reduction of premiums on which
Part III – Insurance Contracts
nonadmitted insurance tax was paid.
Enter the total premiums returned, quarter/year
Column a – Enter the policy number for each
taxed, and the policy number from the time the
contract. Enter only policies related to risks within
returned premiums were originally taxed, on
the U.S.
the lines provided on Form 570. If the returned
Column b – Enter the name of all the Nonadmitted
premiums are from more than one quarter or
Insurance Companies for each contract.
policy, attach a schedule showing the amount
Column c – Enter the type of insurance coverage
of returned premiums from each quarter and/or
provided by the contract.
policy.
Column d – Enter the full name or the two letter
Returned premiums must be claimed on a return
abbreviation of the state where the risk is located
for the calendar quarter during which the returned
for each contract. If your policy covers more than
premiums were received. Refunds resulting from
one state, then use additional lines to list the
returned premiums must be claimed within four
locations of the risk separately.
years from the original due date of the return, four
Column e – Enter the total premium amount for
years from the date the return was filed, or one
each contract.
year from the date of cancellation or reduction of
premium, whichever is later.
Total – Enter the total of Form 570, Side 2,
column e.
Page 2 Form 570 Instructions 2014
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