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Application for Tentative Refund

1045

OMB No. 1545-0098

Form

See separate instructions.

2006

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

Martha Sanders

123-00-4567

Number, street, and apt. or suite no. If a P.O. box, see page 3 of the instructions.

Spouse’s social security number (SSN)

9876 Holly Street

City, town or post office, state, and ZIP code. If a foreign address, see page 3 of the instructions.

Daytime phone number

(

)

Yardley, PA 19067

041

123-4567

This application is

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

Unused general business credit

Net section 1256 contracts loss

filed to carry back:

10,000

For the calendar year 2006, or other tax year

Date tax return was filed

beginning

, 2006, ending

, 20

3-5-2007

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 3 of the instructions)?

Yes

2nd

1st

preceding

Computation of Decrease in Tax

12-31-04

12-31-05

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

10,000

page 3 of the instructions)

50,000

40,000

Adjusted gross income

13,250

14,000

Deductions (see page 4 of the instructions)

36,750

26,000

Subtract line 12 from line 11

3,100

Exemptions (see page 5 of the instructions)

33,650

22,900

Taxable income. Line 13 minus line 14

Income tax. See page 5 of the

5,156

3,081

instructions and attach an explanation

Alternative minimum tax

5,156

3,081

Add lines 16 and 17

General business credit (see page 5

of the instructions)

Other credits. Identify

Total credits. Add lines 19 and 20

5,156

3,081

Subtract line 21 from line 18

6,120

Self-employment tax

Other taxes

11,276

9,201

Total tax. Add lines 22 through 24

Enter the amount from the “After

9,201

carryback” column on line 25 for

9,201

each year

Decrease in tax. Line 25 minus line 26

2,075

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

Martha Sanders

4-11-2007

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,

Cat. No. 10670A

Form

(2006)

see page 8 of the instructions.

Publication 536 (2006)

Page 11

Publication 536 - Net Operating Losses (Nols) For Individuals, Estates, And Trusts - Internal Revenue Service - 2006 Page 11

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