R-620INS (1/17)
                                                                                                                      FILING PERIOD  
                           Request for Refund of Louisiana 
                           Citizens Property Insurance                              Corporation or  
                           Corporation Assessment                                   Nontaxable Entity                    2017

  Legal Name                                                                                                          Louisiana Revenue 
➜                                                                                                                     Account Number
  Trade Name
➜                                                                                   If you DO NOT have a Louisiana Revenue  
                                                                                    Account Number, mark this box.
  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, 2017, and December 31, 2017 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
Calculate the Refund of Louisiana Citizens Property assessment below. Act 9 of the 2016 Second Extraordinary Session of the Louisiana 
Legislature reduced the credit to 25% of the assessment paid.

1. Enter the amount of the total assessment paid.  ........................................   

2. 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.

Enter name of officer                                          Signature of preparer

Signature of officer                                           Firm name

Title of officer                                               Date (mm/dd/yyyy)                Telephone

Telephone                  Date (mm/dd/yyyy)

SPEC
CODE

                                        Area code and daytime                       MAIL TO: 
                                        telephone number
                                                                        Louisiana Department of Revenue
                                                                                 P. O. Box 3576                             2650
                                                                        Baton Rouge, LA 70821-3576

R-620INS(i) (1/17)
                                       Instructions for Preparing Your 2017 Louisiana 
                        Request for Refund of Louisiana Citizens Property Insurance 
                                          Corporation Assessment (R-620INS)

SPEC              This space at the bottom of the form is to be used only when specifically instructed by LDR. Otherwise, leave 
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.  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 2017. 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 may 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.

•  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 2017 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.

9.  Sign and date the return. Mail to:       Louisiana Department of Revenue 
                                                         P. O. Box 3576  
                                             Baton Rouge, LA 70821-3576