Form 1139 - Corporation Application For Tentative Refund
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11139
Corporation Application for Tentative Refund
Form
(Rev. May 1999)
OMB No. 1545-0582
Read the separate instructions before completing this form.
Department of the Treasury
Do not attach to the corporation’s income tax return—mail in a separate envelope.
Internal Revenue Service
Name
Employer identification number
Number, street, and room or suite no. (If a P.O. box, see separate instructions.)
Date of incorporation
City or town, state, and ZIP code
Telephone number (optional)
(
)
$
a
Net operating loss (NOL) (attach computation)
1
This application is
c Unused general business
filed to carry back:
$
$
b
Net capital loss (attach computation)
credit (attach computation)
c Service center where filed
a Tax year ended
b Date filed
2
Return for year of loss, unused credit, or
overpayment under section 1341(b)(1)
3
If this application is for an unused credit created by another carryback, enter ending date for the tax year of the first carryback
4
Does the NOL or net capital loss result in the release of foreign tax credits or the release of other tax credits
because of the release of a foreign tax credit? (see instructions)
Yes
No
If “Yes,” you cannot file Form 1139. Instead, use Form 1120X.
5a
Was a consolidated return filed for any tax year covered on this application?
Yes
No
b
If “Yes,” identify the year and enter the name of the common parent and its EIN, if different from above
6a If Form 1138 has been filed, was an extension of time granted for filing the return for the tax year of the NOL?
Yes
No
b
If “Yes,” give date to which extension was granted
c
Give date Form 1138 was filed
d
Unpaid tax for which Form 1138 is in effect
7
If you changed your accounting period, give date permission to change was granted
8
If this is an application of a dissolved corporation, enter date of dissolution
9
Have you filed a petition in Tax Court for the year or years to which the carryback is to be applied?
Yes
No
Yes
No
10
Does this carryback include a loss or credit from a tax shelter required to be registered? If “Yes,” attach Form(s) 8271
Complete questions 11a and 11b only for the carryback of an NOL that arose in a tax year ending before October 22, 1998.
11a Does the carryback include a specified liability loss that is attributable to a product liability?
Yes
No
b Does the carryback include a specified liability loss that is attributable to a Federal or state law or to a tort other
than product liability?
Yes
No
If the answer to question 11a or 11b is “Yes,” see the instructions and attach a statement.
3rd preceding tax
2nd preceding tax
1st preceding tax
Computation of
year ended
year ended
year ended
Decrease in Tax
(a) Before
(b) After
(c) Before
(d) After
(e) Before
(f) After
Note: If no entry in 1a or 1b, skip lines 12–16.
carryback
carryback
carryback
carryback
carryback
carryback
12
Taxable income from tax return
13
Capital loss carryback (see instructions)
14
Subtract line 13 from line 12
15
NOL deduction (see instructions)
16
Taxable income (subtract line 15 from line 14)
17
Income tax
18
General business credit (see instructions)
19
Other credits (identify)
20
Total credits (add lines 18 and 19)
21
Subtract line 20 from line 17
Personal holding company tax (Sch. PH (Form 1120))
22
23
Recapture taxes
24
Alternative minimum tax and environmental tax
25
Total tax liability (add lines 21 through 24)
26
Recomputed tax liability (see instructions)
27
Decrease in tax (subtract line 26 from line 25)
28
Overpayment of tax due to a claim of right adjustment under section 1341(b)(1)—attach computation
Under penalties of perjury, I declare that I have examined this application and accompanying schedules and statements, and to the best of my
Sign
knowledge and belief, they are true, correct, and complete.
Here
Keep a copy of
Signature of officer
Date
Title
this application
for your records.
Date
Preparer Other
Name
Than Taxpayer
Address
1139
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 11170F
Form
(Rev. 5-99)
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