Form Cdi Fs-003 - Title Insurance Tax Return

Form Cdi Fs-003 - Title Insurance Tax Return - 2013 Page 2

State of California

Department of Insurance

TITLE INSURANCE TAX RETURN

CDI FS-003 (REV 9/2013)

2013

FOR CALENDAR YEAR

TAX DUE DATE APRIL 1, 2014

Name of Insurer

Fed Tax I.D. No.

CA Perm No.

NAIC No.

DECLARATION OF INSURER

This return must be signed by an Executive Officer, United States Manager, or Manager residing within

California, pursuant to California Revenue and Taxation Code Section 12303.

Type or print Name

Type or print Title

Type or print Name of Company

hereby declare under penalty of perjury that this return (including the accompanying schedules and

statements) has been examined by me and is a true, correct, and complete return.

Signature

Date

City

State

SPACE FOR NOTARY

State of _______________________________

County of _____________________________________________

On this _____________ day of __________________20 _______ before me personally appeared ___________________________

who is personally known to me as the __________________________ of ______________________________________________

and who has taken an oath that the foregoing is true, correct and complete.

Seal:

__________________________________

Print or type Name and sign above the line

Contact person for this tax return:

Name:

Title:

Type or Print

Phone:

Fax Number:

E-Mail

Address if different from Page 1

Mailing Address

City, State, Zip

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Form Cdi Fs-003 - Title Insurance Tax Return - 2013 Page 2