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1045

Application for Tentative Refund

OMB No. 1545-0098

Form

2011

See separate instructions.

Do not attach to your income tax-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

123-00-4567

Martha Sanders

Number, street, and apt. or suite no. if a P.O. box, see instructions.

Spouse’s social security number (SSN)

9876 Holly Street

City, town or post of ce, state, and Zip code. If a foreign address, also complete spaces below (see instructions).

Daytime phone number

041-123-4567

Yardley, PA 19067

Foreign country name

Foreign province/county

Foreign postal code

1 This application is led

a Net operating loss (NOL) (Sch. A, line 25, page 2)

b Unused general business credit

c Net section 1256 contracts loss

to carry back:

10,000

2 a

For the calendar year 2011, or other tax year

b Date tax return was led

03-05-2012

n i

, 1

n i

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

If you led a joint return (or separate return) for some, but not all, of the tax years involved in guring 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 led 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 resulting from a reportable transaction required to be

disclosed on Form 8886, Reportable Transaction Disclosure Statement? .

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 instructions)? .

Yes

Computation of Decrease in Tax

2nd

1st

preceding

(see instructions)

12-31-09

12-31-10

tax year ended

Before

After

Before

After

Before

After

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

carryback

NOL deduction after carryback (see instructions)

10,000

Adjusted gross income

50,000

40,000

13,250

Deductions (see instructions)

14,000

Subtract line 12 from line 11

36,750

26,000

Exemptions (see instructions)

3,650

33,100

22,350

Taxable income. Line 13 minus line 14

Income

tax.

See

instructions

and

attach an explanation .

4,544

2,939

Alternative minimum tax .

Add lines 16 and 17

4,544

2,939

General business credit (see instructions)

Other credits. Identify .

Total credits. Add lines 19 and 20 .

4,544

Subtract line 21 from line 18

2,939

Self-employment tax .

6,120

Other taxes .

Total tax. Add lines 22 through 24 .

10,664

9,059

Enter

the

amount

from

the

“After

carryback” column on line 25 for each year

9,059

1,605

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

Martha Sanders

04-12-2012

Keep a copy of

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

Date

this application

for your records.

Preparer’s signature

Date

PTIN

Print/Type preparer’s name

Check

Paid

self-employed

Preparer

Firm’s name

Firm's EIN

Use Only

Firm’s address

Phone no.

1045

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions.

Form

(2011)

Cat. No. 10670A

Publication 536 (2011)

Page 11

Publication 536 - Net Operating Losses (Nols) For Individuals, Estates, And Trusts - 2011 Page 11

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