Form Cit-624 - Louisiana Corporation Income Tax
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1
2CIT-624
State of Louisiana
R-6701 (3/01)
Department of Revenue
P.O. Box 201
Baton Rouge, LA 70821-0201
Louisiana
Louisiana Revenue Account Number
Corporation
Income Tax
Name
Request for a tentative refund resulting
Street address
from the election to carry back a net
operating loss
City, State, ZIP
Schedule A: Computation of loss amount available for carryback and carryforward
1. Net operating loss incurred for tax year ended
1 $
..............................................
2. Federal tax refund or credit applicable to the loss
2 $
(Attach copy of Federal Form 1139, or explanation.) ......
3. Net operating loss available for carryback
3 $
(Subtract Line 2 from Line 1.) .........................................................
4. Amount of loss utilized in Schedule B
4 $
(Line 3 below) .........................................................................................
5. Net operating loss available for carryforward
5 $
(Subtract Line 4 from Line 3.) ...................................................
Schedule B: Computation of tentative refund amount
Third preceding tax year
Second preceding tax year
First preceding tax year
ended
ended
ended
1. Net taxable income previously
reported
2. Net operating loss previously
applied
3. Current loss carryback
(Schedule A, Line 4)
4. Net taxable income (Subtract
Lines 2 and 3 from Line 1.)
5. Income tax liability
(Based on Line 4)
6. New job credits (Limited to 50%)
7. Other Credits
8. Net tax due (Subtract Lines 6
and 7 from Line 5.)
9. Net tax previously paid
10. Tentative refund (Subtract Line 9
from Line 8.)
Signature and Verification
This request is made pursuant to Revised Statute 47:287.86.G, allowing the Secretary the discretion to pay certain
refunds on a tentative basis subject to later verification and recovery of any amount found not to be a valid
overpayment under the law. I declare that I have examined this request, and to the best of my knowledge and belief,
it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which
he has any knowledge.
(Signature of officer)
Title
Date
Signature of preparer
Date
(
)
(
)
Telephone number
Telephone number of preparer
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