Louisiana Refund Request of LA Citizens for Property Insurance-Individual

Refund Request of LA Citizens for Property Insurance-Individual
Form R-540INS (Obsolete)
R-540INS (1/19)

FILING PERIOD

Individual
Income Tax

Request for Refund of Louisiana
Citizens Property Insurance
Corporation Assessment

Your first name

MI

Last name

Suffix

If joint return, spouse’s name

MI

Last name

Suffix

2019

Your Social
Security Number

➜

Spouse’s Social
Security Number

➜

Area code and
daytime telephone
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 equal to 25 percent of the Louisiana Citizens Property Insurance
assessment that you paid between January 1, 2019, and December 31, 2019, as a part of your 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. Enter the amount of your paid assessment below on Line 1.
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. Enter the total
amount of the assessments paid for all properties listed on the Supplement Schedules on Line 1 below.
YOU MUST ATTACH A COPY OF YOUR INSURANCE DECLARATION PAGE FOR ALL PROPERTIES.
REFUND
1.	 Enter the amount of the total assessment paid.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
2.	 REFUND - Multiply Line 1 by 25 percent (.25).  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer 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.
Your Signature

Date (mm/dd/yyyy)

Print Preparer’s Name

Spouse’s Signature (If filing jointly, both must sign)

Preparer’s Signature

Date (mm/dd/yyyy)
Check

PAID
PREPARER
USE ONLY

Firm’s Name

➤

Firm’s FEIN

➤

Firm’s Address

➤

Telephone

➤

MAIL TO:
Louisiana Department of Revenue
P. O. Box 3576
Baton Rouge, LA 70821-3576

For Office
Use Only.

Date (mm/dd/yyyy)

■

if Self-employed

PTIN, FEIN, or LDR Account Number
of Paid Preparer

6977

R-540INS(i) (1/19)

Instructions for Preparing your 2019 Louisiana Request
for Refund of Louisiana Citizens Property Insurance
Corporation Assessment (R-540INS)

Mail return to:
Louisiana Department of Revenue
P. O. Box 3576
Baton Rouge, LA 70821-3576

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 2019.
2.	 Enter the amount only on the line that is applicable.
3.	 Complete the form by using a pen with black ink.
4.	 Because this form is read by a machine, please enter your numbers inside the boxes like this:

1	2	3	4	5

5.	 All numbers should be rounded to the nearest dollar.
6.	 Numbers should NOT be entered 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) – Enter your name(s), address, and Social Security Number(s) in the space
provided. If married, please enter 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 assessment paid 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.
•	 Enter 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 2019 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 enter the total on Line 1.
9.	 Sign and date the return. Mail the return to the address at the top of this form. 	
Paid Preparer Instructions
If your return was prepared by a paid preparer, that person must also sign in the appropriate space, complete the information in the
“Paid Preparer Use Only” box and enter his or her identification number in the space provided under the box. If the paid preparer has a
Preparer Tax Identification Number (PTIN), the PTIN must be entered in the space provided under the box, otherwise enter the Federal
Employer Identification Number (FEIN) or LDR account number. If the paid preparer represents a firm, the firm’s FEIN must be entered in
the “Paid Preparer Use Only” box. The failure of a paid preparer to sign or provide an identification number will result in the assessment
of the unidentified preparer penalty on the preparer. The penalty of $50 is for each occurrence of failing to sign or failing to provide an
identification number.