R-540INS (1/19) 
                                                                                                                                    FILING PERIOD  
                                  Request for Refund of Louisiana                              Individual  
                                    Citizens Property Insurance 
                                    Corporation Assessment                              Income Tax                                  2019

  Your first name                        MI Last name                            Suffix                                             Your Social 
➜                                                                                                                                   Security Number
  If joint return, spouse’s name         MI Last name                            Suffix                                             Spouse’s Social 
➜                                                                                                                                   Security Number
  Current home address (number and street including apartment number or rural route)                                                    Area code and  
➜                                                                                                                                       daytime telephone 
                                                                                                                                        number
  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)    Spouse’s Signature (If filing jointly, both must sign) Date (mm/dd/yyyy)

                   Print Preparer’s Name                Preparer’s Signature                   Date (mm/dd/yyyy)
                                                                                                                 Check ■            if Self-employed
  PAID
PREPARER             Firm’s Name ➤                                                             Firm’s FEIN ➤
USE ONLY
                   Firm’s Address ➤                                                                Telephone ➤

                                         MAIL TO:                     For Office        PTIN, FEIN, or LDR Account Number 
                                                                      Use Only.                of Paid Preparer
                                 Louisiana Department of Revenue
                                         P. O. Box 3576                                                                                  6977
                                  Baton Rouge, LA 70821-3576

R-540INS(i) (1/19)
                                                                                                       Mail return to:
                          Instructions for Preparing your 2019 Louisiana Request 
                                                                                                       Louisiana Department of Revenue
                          for Refund of Louisiana Citizens Property Insurance                          P. O. Box 3576
                                  Corporation Assessment (R-540INS)                                    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.