R-540INS (1/14)
Filing Period
individual
request for refund of louisiana
2014
Citizens Property insurance
income Tax
Corporation Assessment
Your first name
MI Last name
Suffix
Your Social
➜
➜
Security Number
If joint return, spouse’s name
MI Last name
Suffix
Spouse’s Social
➜
➜
Security Number
Current home address (number and street including apartment number or rural route)
➜
City, town, or APO
State
ZIP
For amended return, mark this box.
➜
Louisiana Revised Statute 47:6025 allows a refundable tax credit to reimburse citizens who paid between January 1, 2014, and
December 31, 2014, an assessment to fund the Louisiana Citizens Property Insurance Program as a part of their homeowner’s insurance
premium. You may claim the Louisiana Citizens Property Insurance Corporation assessment refund on this form or on your individual
income tax return, but not on both forms. Claiming the refund on both forms will delay your individual income tax return for review.
one Property
If you 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 your paid assessment below on Line 1, Total
.
Request for Refund of Louisiana Citizens Property Insurance Corporation Assessment
Address of Property
Insurance Company
Policy Number
More Than one Property
If you 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 the 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
,
.
00
1.
Total Request for Refund of Louisiana Citizens Property Insurance Corporation Assessment. . . . ➜
I declare that I have examined this return, and to the best of my knowledge, it is true and complete. Declaration of paid preparer is based
on all available information. 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.
Your Signature
Date
Signature of paid preparer other than taxpayer
(mm/dd/yyyy)
Spouse’s Signature (If filing jointly, both must sign.)
Date
Telephone number of paid preparer
Date
(mm/dd/yyyy)
(mm/dd/yyyy)
SPeC
Code
Area code and daytime
MAIL TO:
telephone number
Louisiana Department of Revenue
6790
P. O. Box 3576
Baton Rouge, LA 70821-3576