Form 1139 Corporation Application for Tentative Refund

1139

Form
(Rev. December 2012)
Department of the Treasury
Internal Revenue Service

Corporation Application for Tentative Refund
▶

Information about Form 1139 and its separate instructions is at www.irs.gov/form1139.
▶ Do not file with the corporation’s income tax return—file separately.
▶ Keep a copy of this application for your records.

OMB No. 1545-0582

Name

Employer identification number

Number, street, and room or suite no. If a P.O. box, see instructions.

Date of incorporation

City or town, state, and ZIP code

Daytime phone number

1

Reason(s) for filing.
See instructions—
attach computation

a Net operating loss (NOL) . . ▶ $
b Net capital loss
. . . . ▶ $
a
Tax
year ended
Return for year of loss, unused credit, or

2

overpayment under section 1341(b)(1)

c Unused general
business credit

▶

$
d Other
. .
$
b Date tax return filed c Service center where filed
▶

▶

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

Did a loss result in the release of a foreign tax credit, or is the corporation carrying back a general business credit that
was released because of the release of a foreign tax credit (see instructions)? If “Yes,” the corporation must file an
amended return to carry back the released credits . . . . . . . . . . . . . . . . . . . .

5a
b

Yes
Yes
Was a consolidated return filed for any carryback year or did the corporation join a consolidated group (see instructions)?
If “Yes,” enter the tax year ending date and the name of the common parent and its EIN, if different from above (see instructions) ▶

6a
b

If Form 1138 has been filed, was an extension of time granted for filing the return for the tax year of the NOL?
.
If “Yes,” enter the date to which extension was granted ▶
c Enter the date Form 1138 was filed .

d

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Unpaid tax for which Form 1138 is in effect . . . . . . . . . . . . . . . . .
If the corporation changed its accounting period, enter the date permission to change was granted .

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8

If this is an application for a dissolved corporation, enter date of dissolution .

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Has the corporation filed a petition in Tax Court for the year or years to which the carryback is to be applied? .

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9
10

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preceding
tax year ended ▶
(a) Before
(b) After
carryback
carryback

Note: If only filing for an unused general business
credit (line 1c), skip lines 11 through 15.

tax year ended ▶
(c) Before
(d) After
carryback
carryback

Taxable income from tax return .

12
13
14
15
16
17
18
19
20
21
22
23
24
25

Capital loss carryback (see instructions)
Subtract line 12 from line 11 . . . . .
NOL deduction (see instructions)
. .
Taxable income. Subtract line 14 from line 13
Income tax
. . . . . . . . .
Alternative minimum tax . . . . . .
Add lines 16 and 17 . . . . . . .
General business credit (see instructions)
Other credits (see instructions) . . . .
Total credits. Add lines 19 and 20 . . .
Subtract line 21 from line 18 . . . . .

26

Enter amount from “After carryback”
column on line 25 for each year . . . .

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)

.

Yes

No

$

Yes

preceding

11

.

No

▶

Is any part of the decrease in tax due to a loss or credit resulting from a reportable transaction required to be
disclosed? If Yes, attach Form 8886 . . . . . . . . . . . . . . . . . . . . . . . .
Computation of Decrease in Tax
See instructions.

Yes

▶

7

.

No
No

No
preceding

tax year ended ▶
(e) Before
(f) After
carryback
carryback

.

Personal holding company tax (Sch. PH (Form 1120))

Other taxes (see instructions) . . . .
Total tax liability. Add lines 22 through 24

Signature of officer

Print/Type preparer’s name

Preparer's signature

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▲

Paid
Preparer
Use Only

▲

Sign
Here

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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.

Date
Date

Title
Check
if
self-employed

Firm’s name

▶

Firm's EIN

Firm's address

▶

Phone no.

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 11170F

PTIN

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Form 1139 (Rev. 12-2012)