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Form R-540INS Fillable Refund Request of LA Citizens for Property Insurance-Individual
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)
(checkbox) Unchecked (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 1 Total Request for Refund of Louisiana Citizens Property Insurance Corporation Assessment 3 4 5 00 1 2 4 Because this form is read by a machine please print your numbers inside the boxes like this: About this Form Address of Property All numbers should be rounded to the nearest dollar amount of the assessments paid for all properties listed on the Supplement Schedules on Line 1 the Total Request for Refund of An individual may file this form to claim the refund of the Louisiana Citizens Property Insurance Corporation assessment(s) that was Area code and daytime Assessment (r 540inS) assessment? Baton Rouge LA 70821 3576 blank Citizens Property insurance Citizens Property insurance Corporation Citizens Property Insurance Corporation Assessment City town or APO companies to provide the Citizens Insurance Assessment information to the Louisiana Department of Revenue upon request company s name and the insurance policy number in the boxes below Print the amount of your paid assessment below on Line 1 Total Complete the form by using a pen with black ink Corporation Assessment Current home address (number and street including apartment number or rural route) Date (mm/dd/yyyy) December 31 2013 an assessment to fund the Louisiana Citizens Property Insurance Program as a part of their homeowner s insurance delays caused by manual processing taxpayers should follow the guidelines listed below: Failure to attach the Insurance Declaration Page(s) will result in this form being returned to you FAIR Plan eMergenCy Assessment Louisiana Citizens Coastal Plan regulAr Assessment and/or Louisiana Citizens Coastal Filing Period For amended return mark this box 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 If joint return spouse s name If married please print Social Security Numbers for both you and your spouse If you are filing an amended return mark an X in the Amended Return box If you had more than one property during 2013 that incurred an assessment prepare and attach Form R INS Supplement For more If you paid the Louisiana Citizens Property Insurance Corporation assessment for more than one property complete the Supplement If you paid the Louisiana Citizens Property Insurance Corporation assessment for only one property list the property s address the insurance important note: if you are a customer of the louisiana Citizens insurance Corporation and you paid the Tax exempt Surcharge income Tax income tax return but not on both forms Claiming the refund on both forms will delay your individual income tax return for review incurred individual information concerning the assessment amounts and insurance declaration Page The amount of this assessment may appear as instructions for Preparing your 2013 Insurance Company Last name Louisiana Citizens Property Insurance Corporation Assessment Louisiana Department of Revenue louisiana request for refund of louisiana Louisiana Revised Statute 47:6025 allows a refundable tax credit to reimburse citizens who paid between January 1 2013 and MAIL TO: More Than one Property name(s) address and Social Security number(s) Print your name(s) address and Social Security Number(s) in the space provided names the policyholder describes the property or liability to be insured type of coverage and policy limits Depending on the location of Numbers should NOT be printed over the pre printed zeros in the boxes on the far right which are used to designate cents ( 00) of the assessments that appear on the R INS Supplement Form and print the total on Line 1 Total Request for Refund of Louisiana on all available information I also consent that the Louisiana Department of Revenue may contact my insurance company/companies to one Property P O Box 3576 paid during calendar year 2013 Plan eMergenCy Assessment Your total allowable credit is the total of these amounts if they are shown on the Declaration Page Policy Number premium You may claim the Louisiana Citizens Property Insurance Corporation assessment refund on this form or on your individual Print the address of the property the insurance company s name and the policy number in the spaces provided Print the amount only on the line that is applicable property R 540INS (1/13) R 540INS(i) (1/13) reFund request for refund of louisiana Request for Refund of Louisiana Citizens Property Insurance Corporation Assessment Schedule for Refund of Louisiana Citizens Property Assessment Form R INS Supplement and attach it to this return Print the total Security Number separate line items on what is referred to as the declaration Page of your property insurance premium notice The Declaration Page Sign and date the return Mail to: Louisiana Department of Revenue Signature of paid preparer other than taxpayer Spouse s Signature (If filing jointly both must sign ) Date (mm/dd/yyyy) Spouse s Social State Suffix telephone number Telephone number of paid preparer than four properties use additional R INS Supplement forms You must attach the Declaration Page for each property listed Add all the insured property these line item charges may be listed as: Louisiana Citizens FAIR Plan regulAr Assessment Louisiana Citizens The return has been designed for electronic scanning which permits faster processing with fewer errors In order to avoid unnecessary This space at the bottom of the form is to be used only when specifically instructed by LDR Otherwise leave this surcharge may not be claimed verify the amount of the Louisiana Citizens Property Insurance Corporation assessment paid and I further direct my insurance company/ You must attach a copY of Your insurance declaration page for all properties Your first name Your Signature Date (mm/dd/yyyy) Your Social