R-540INS (1/17) 
                                                                                                                        FILING PERIOD  
                                 Request for Refund of Louisiana                    Individual  
                                 Citizens Property Insurance 
                                 Corporation Assessment                             Income Tax                               2017

  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)
➜
  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, 2017, and December 31, 2017 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
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).   ....................................................

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 
on all available information. 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) Signature of paid preparer other than taxpayer

Spouse’s Signature (If filing jointly, both must sign.) Date (mm/dd/yyyy) Telephone number of paid preparer             Date (mm/dd/yyyy)
                                                                          (        )

SPEC
CODE

                                 Area code and daytime  
                                    telephone number                                MAIL TO: 
                                                                                    Louisiana Department of Revenue
                                                                                    P. O. Box 3576                           6660
                                                                                    Baton Rouge, LA 70821-3576

R-540INS(i) (1/17)
                        Instructions for Preparing your 2017 Louisiana Request 
                        for Refund of Louisiana Citizens Property Insurance 
                                        Corporation Assessment (R-540INS)

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.  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 2017.
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 2017 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 to:            Louisiana Department of Revenue 
                                                  P. O. Box 3576  
                                                  Baton Rouge, LA 70821-3576