Form R-540ins - Request For Refund Of Louisiana Citizens Property Insurance Corporation Assessment - 2014 Page 2

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R-540INS(i) (1/14)
instructions for Preparing your 2014 louisiana request
for refund of louisiana Citizens Property insurance
Corporation Assessment (r-540inS)
This space at the bottom of the form is to be used only when specifically instructed by LDR. Otherwise, leave
SPeC
Code
blank.
About this Form
The return has been designed for electronic scanning, which permits faster processing with fewer errors. In order to avoid unnecessary
delays caused by manual processing, taxpayers should follow the guidelines listed below:
1.
An individual may file this form to claim the refund of the Louisiana Citizens Property Insurance Corporation assessment(s) that was
paid during calendar year 2014.
2.
Print the amount only on the line that is applicable.
3.
Complete the form by using a pen with black ink.
,
.
1 2
3 4 5
00
Because this form is read by a machine, please print your numbers inside the boxes like this:
4.
5.
All numbers should be rounded to the nearest dollar.
6.
Numbers should NOT be printed over the pre-printed zeros, in the boxes on the far right, which are used to designate cents (.00).
7.
If you are filing an amended return, mark an “X” in the “Amended Return” box.
8.
Failure to attach the Insurance Declaration Page(s) will result in this form being returned to you.
name(s), address, and Social Security number(s) – Print your name(s), address, and Social Security Number(s) in the space
provided. If married, please print Social Security Numbers for both you and your spouse.
information concerning the assessment amounts and insurance declaration Page – The amount of this assessment may appear as
separate line items on what is referred to as the “declaration Page” of your property insurance premium notice. The Declaration Page
names the policyholder, describes the property or liability to be insured, type of coverage, and policy limits. Depending on the location of
the insured property, these line item charges may be listed as: Louisiana Citizens FAIR Plan regulAr Assessment, Louisiana Citizens
FAIR Plan eMergenCy Assessment, Louisiana Citizens Coastal Plan regulAr Assessment, and/or Louisiana Citizens Coastal
Plan eMergenCy Assessment. Your total allowable credit is the total of these amounts, if they are shown on the Declaration Page.
important note: if you are a customer of the louisiana Citizens insurance Corporation and you paid the Tax exempt Surcharge,
this surcharge may not be claimed.
• Print the address of the property, the insurance company’s name, and the policy number in the spaces provided.
• Do you own more than one property that incurred an assessment?
If you had more than one property during 2014 that incurred an assessment, prepare and attach Form R-INS Supplement. For more
than four properties, use additional R-INS Supplement forms. You must attach the Declaration Page for each property listed. Add all
of the assessments that appear on the R-INS Supplement Form, and print the total on Line 1, Total Request for Refund of Louisiana
Citizens Property Insurance Corporation Assessment.
9.
Sign and date the return. Mail to:
Louisiana Department of Revenue
P. O. Box 3576
Baton Rouge, LA 70821-3576.
6791

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