R-620INS (1/19)
                                                                                                                     FILING PERIOD  
                           Request for Refund of Louisiana 
                                    Citizens Property Insurance                    Corporation or  
                                    Corporation Assessment                         Nontaxable Entity                     2019

  Legal Name                                                                                                         Louisiana Revenue 
➜                                                                                                                    Account Number
  Trade Name
➜                                                                                  If you DO NOT have a Louisiana Revenue  
                                                                                   Account Number, mark this box.
  Address                                                                                                                Area code & 
➜                                                                                                                        daytime telephone  
                                                                                                                         number
  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)              Telephone

                   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 
                           Louisiana Department of Revenue     Use Only.           of Paid Preparer
                                         P. O. Box 3576                                                                    2955
                                  Baton Rouge, LA 70821-3576

R-620INS(i) (1/19)
                                                                                                  Mail return to:
                                  Instructions for Preparing the 2019 Louisiana 
                                                                                                  Louisiana Department of Revenue
                          Request for Refund of Louisiana Citizens Property Insurance             P. O. Box 3576
                                          Corporation Assessment (R-620INS)                       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.