Fillable 2004 Form 1045 - Application For Tentative Refund printable pdf download

Application for Tentative Refund

1045

OMB No. 1545-0098

Form

See separate instructions.

2004

Do not attach to your income tax return—mail in a separate envelope.

Department of the Treasury

For use by individuals, estates, or trusts.

Internal Revenue Service

Name(s) shown on return

Social security or employer identification number

Number, street, and apt. or suite no. If a P.O. box, see page 2 of the instructions.

Spouse’s social security number (SSN)

City, town or post office, state, and ZIP code. If a foreign address, see page 2 of the instructions.

Daytime phone number

(

)

This application is

Net operating loss (NOL) (Sch. A, line 24, page 2)

Unused general business credit

Net section 1256 contracts loss

filed to carry back:

For the calendar year 2004, or other tax year

Date tax return was filed

beginning

, 2004, ending

, 20

If this application is for an unused credit created by another carryback, enter year of first carryback

If you filed a joint return (or separate return) for some, but not all, of the tax years involved in figuring the carryback, list the

years and specify whether joint (J) or separate (S) return for each

If SSN for carryback year is different from above, enter a SSN

and b Year(s)

If you changed your accounting period, give date permission to change was granted

Have you filed a petition in Tax Court for the year(s) to which the carryback is to be applied?

Yes

Is any part of the decrease in tax due to a loss or credit from a tax shelter required to be registered?

Yes

If you are carrying back an NOL or net section 1256 contracts loss, did this cause the release of foreign tax credits

or the release of other credits due to the release of the foreign tax credit (see page 2 of the instructions)?

Yes

preceding

Computation of Decrease in Tax

tax year ended

(see page 3 of the instructions)

Before

After

Before

After

Before

After

Note: If 1a and 1c are blank, skip lines 10 through 15.

carryback

NOL deduction after carryback (see

page 3 of the instructions)

Adjusted gross income

Deductions (see page 4 of the instructions)

Subtract line 12 from line 11

Exemptions (see page 4 of the instructions)

Taxable income. Line 13 minus line 14

Income tax. See page 4 of the

instructions and attach an explanation

Alternative minimum tax

Add lines 16 and 17

General business credit (see page 4

of the instructions)

Other credits. Identify

Total credits. Add lines 19 and 20

Subtract line 21 from line 18

Self-employment tax

Other taxes

Total tax. Add lines 22 through 24

Enter the amount from the “After

carryback” column on line 25 for

each year

Decrease in tax. Line 25 minus line 26

Overpayment of tax due to a claim of right adjustment under section 1341(b)(1) (attach computation)

Sign

Under penalties of perjury, I declare that I have examined this application and accompanying schedules and statements, and to the best of my

knowledge and belief, they are true, correct, and complete.

Here

Your signature

Date

Keep a copy of

this application

for your records.

Spouse’s signature. If Form 1045 is filed jointly, both must sign.

Date

Name

Preparer Other

Than Taxpayer

Address

1045

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 7 of the instructions.

Cat. No. 10670A

Form

(2004)

2004 Form 1045 - Application For Tentative Refund

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