Form R-620ins - Request For Refund Of Louisiana Citizens Property Insurance Corporation Assessment

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R-620INS (1/14)

Filing Period

request for refund of louisiana

2014

Corporation or

Citizens Property insurance

nontaxable entity

Corporation Assessment

Louisiana Revenue

Legal Name

➜

Account Number

➜

Trade Name

If you DO NOT have a Louisiana Revenue

➜

Account Number, mark this box.

Address

➜

City

State

ZIP

➜

For amended return, mark this box.

Louisiana Revised Statute 47:6025 allows a refundable tax credit to reimburse a corporation or a nontaxable entity that paid between

January 1, 2014, and December 31, 2014, an assessment to fund the Louisiana Citizens Property Insurance Program as a part of its

property insurance premium. You may claim the Louisiana Citizens Property Insurance Corporation assessment refund on this form or

on the entity’s income tax return, but not on both forms. Claiming the refund on both forms will delay the income tax return for review.

one Property

If the corporation or nontaxable entity 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. Print the amount of the paid

assessment below on Line 1, Total Request for Refund of Louisiana Citizens Property Insurance Corporation Assessment.

Address of Property

Insurance Company’s Name

Policy Number

More Than one Property

If the corporation or nontaxable entity 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. Print the total amount of assessments paid for all properties listed on the supplement schedules on Line 1, the Total Request for

Refund of Louisiana Citizens Property Insurance Corporation Assessment.

You MusT ATTACh A CoPY oF Your insurAnCe deClArATion PAge For All ProPerTies.

reFund

1. Total Request for Refund of Louisiana Citizens Property

Insurance Corporation Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

➜

Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, 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 he has any knowledge. 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.

Print name of officer

Signature of preparer

Signature of officer

Firm name

Title of officer

Date

Telephone

(mm/dd/yyyy)

Telephone

Date

(mm/dd/yyyy)

sPeC