Free Form 1139 (Rev. August 2006) - Federal

Form

1139

Corporation Application for Tentative Refund
See separate instructions. Do not file with the corporation's income tax return--file separately.
Employer identification number OMB No. 1545-0582

(Rev. August 2006)
Department of the Treasury Internal Revenue Service

Name

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 $ $

)
$ $

c Unused general business credit d Other

2 3 4

Return for year of loss, unused credit, or overpayment under section 1341(b)(1)

b Date tax return filed c Service center where filed

If this application is for an unused credit created by another carryback, enter ending date for the tax year of the first carryback 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 Was a consolidated return filed for any carryback year or did the corporation join a consolidated group (see instructions)?

Yes Yes

No No

5a b 6a b d 7 8 9 10

If "Yes," enter the tax year ending date and the name of the common parent and its EIN, if different from above (see instructions) 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 Unpaid tax for which Form 1138 is in effect If the corporation changed its accounting period, enter the date permission to change was granted If this is an application for a dissolved corporation, enter date of dissolution Has the corporation filed a petition in Tax Court for the year or years to which the carryback is to be applied? Does this application include a loss or credit from a tax shelter required to be registered? If "Yes," attach Form(s) 8271 Yes Yes No No c Enter the date Form 1138 was filed $ Yes No

Computation of Decrease in Tax See instructions. Note: If only filing for an unused general business credit (line 1c), skip lines 11 through 15. 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Taxable income from tax return 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 Personal holding company tax (Sch. PH (Form 1120)) Other taxes (see instructions) Total tax liability. Add lines 22 through 24

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

preceding tax year ended (d)After carryback (e)Before carryback

preceding (f)After carryback

Enter amount from "After carryback" column on line 25 for each year Decrease in tax. Subtract line 26 from line 25 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 knowledge and belief, they are true, correct, and complete.

Sign Here
Keep a copy of this application for your records.

Signature of officer

Date

Title

Preparer Other Than Taxpayer

Name Address Cat. No. 11170F

Date

For Paperwork Reduction Act Notice, see separate instructions.

Form

1139

(Rev. 8-2006)