Louisiana Request for Refund of LA. Citizens Property Insurance

Request for Refund of LA. Citizens Property Insurance
Form R-620INS (Obsolete)
R-620INS (1/19)

FILING PERIOD

Request for Refund of Louisiana
Citizens Property Insurance
Corporation Assessment

➜
➜
➜
➜

2019

Corporation or
Nontaxable Entity

Legal Name

Louisiana Revenue
Account Number

Trade Name

If you DO NOT have a Louisiana Revenue
Account Number, mark this box.
Area code &
daytime telephone
number

Address
City

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 was paid by a corporation or a nontaxable entity between January 1, 2019, and December 31, 2019 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. Enter the amount of the paid
assessment below on Line 1.
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. Enter the total amount of 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 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.
Name of Officer

Signature of Officer

Title of Officer

Date (mm/dd/yyyy)

Print Preparer’s Name

PAID
PREPARER
USE ONLY

Preparer’s Signature

Telephone

Date (mm/dd/yyyy)

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.

Check

■

if Self-employed

PTIN, FEIN, or LDR Account Number
of Paid Preparer

2955

R-620INS(i) (1/19)

Instructions for Preparing the 2019 Louisiana
Request for Refund of Louisiana Citizens Property Insurance
Corporation Assessment (R-620INS)

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.	 A corporation or nontaxable entity may file this form to claim its refund of the Louisiana Citizens Property Insurance Corporation
assessment(s) that was paid during calendar year 2019. Nontaxable entities include organizations described in either sections 401(a)
or 501 of the Internal Revenue Code such as churches, not-for-profit hospitals, charities, community foundations, as well as public
entities such as municipalities and school boards. The claim for refund is limited only to the amount of the insurance assessment paid
as a result of the additional assessments for Louisiana Citizens Property Insurance Corporation. The amount that is claimed for refund
may not include premium taxes paid.
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	6	7

5.	 All numbers should be rounded to the nearest dollar.
6.	 Numbers should NOT be entered over the pre-entered zeros, in the boxes on the far right, which are used to designate cents (.00).
7.	 If the corporation or nontaxable entity is filing an amended return, mark an “X” in the “Amended Return” box.
8.	 Failure to attach the Insurance Declaration Page will result in the Request for Refund form being returned to you.
Name, address, and Revenue Account Number – Enter the corporation’s or nontaxable entity’s legal name, address, and Revenue
Account Number in the space provided. If the corporation or nontaxable entity does not have a Louisiana Revenue Account Number,
mark the box below the account number field.
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 the 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. The 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. Enter the amount
of the paid assessment in the appropriate boxes on Line 1. Multiply Line 1 by 25 percent (.25) and enter on Line 2.
•	 Does the corporation or nontaxable entity own more than one property that incurred an assessment?
	 If the corporation or nontaxable entity 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. Please 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. Multiply Line 1
by 25 percent (.25) and enter on Line 2.
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.