Form N-109 - Application For Tentative Refund From Carryback Of Net Operating Loss

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FORM

STATE OF HAWAII — DEPARTMENT OF TAXATION

APPLICATION FOR TENTATIVE REFUND FROM CARRYBACK

N-109

OF NET OPERATING LOSS

(REV. 2015)

Do Not Attach to Your Income Tax Return — File Separately to Expedite Processing

For use by individuals, estates, or trusts.

(NOTE: References to “married”, “unmarried”, and “spouse” also means “in a civil union”, “not in a civil union”, and “civil union partner”, respectively.)

CAUTION:

Nonresidents and part-year residents (Form N-15 filers) cannot file this form. See Instructions.

Name(s)

Federal Employer I.D. No. if any

Address (number and street)

Your social security number

City or town, State and Postal/ZIP code

Spouse’s social security number

2 Amount of net operating loss (from page 2, line 10)

1 Return for year of net operating loss

(a) Tax year ended

(b) Date filed

$_______________________________

3 (a) Preceding tax year(s) affected by carryback

(b) Did spouse file a separate return?

CAUTION: In general, a net operating loss may



3rd

Yes

only be carried back 2 years. See item H in the



Instructions for net operating losses that may be

2nd

Yes

carried back more than 2 years.



1st

Yes

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



5 Have you filed a petition in the Tax Appeal Court for the year or years to which the loss is to be applied? . . . . . . . . . . . .

Yes

3rd preceding tax

2nd preceding tax

1st preceding tax

Computation of Decrease in Tax

year ended

(See item H in the Instructions before applying

(a) Before

(b) After

(d) After

(e) Before

(f) After

carryback to the 3rd preceding tax year.)

carryback

6 Adjusted gross income as last determined . . . . . . . . . .

7 Net operating loss deduction resulting from

carryback (attach computation) . . . . . . . . . . . . . . . . . . .

8 Line 6 minus line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9 Deductions (see Instructions) . . . . . . . . . . . . . . . . . . . .

10 Line 8 minus line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11 Exemptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12 Taxable income (line 10 minus line 11) . . . . . . . . . . . . .

13 Income tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14 Refundable tax credits for tax years after 2009

(Nonrefundable tax credits for tax years prior to 2010)

(see Instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 Line 13 minus line 14 (see Instructions) . . . . . . . . . . . .

16 Nonrefundable tax credits for tax years after 2009

(Refundable tax credits for tax years prior to 2010)

(see Instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17 Total tax liability (line 15 minus line 16) . . . . . . . . . . . . .

column (b)

{

18 Enter amount from line 17 . . . . . . . . .

column (d)

column (f)

19 Decrease in tax, line 17 minus line 18 . . . . . . . . . . . . . .

ATTACH A COPY OF YOUR ORIGINAL FEDERAL RETURN FOR THE LOSS YEAR (See Instructions.)

Declaration

I declare, under the penalties set forth in section 231-36, HRS, that I have examined this application, including any accompanying schedules and statements,

and, to the best of my knowledge and belief, it is true, correct, and complete.

(Your signature and date)

(If application is filed jointly by taxpayer and spouse, both must sign)

(Spouse’s signature and date)

FORM N-109