Form 1139
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
Corporation Application for Tentative Refund
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Go to www.irs.gov/Form1139 for instructions and the latest information.
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Do not file with the corporation’s income tax return—file separately.
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Keep a copy of this application for your records.
OMB No. 1545-0123
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) . .
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$
b Net capital loss . . . .
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$
c
Unused general
business credit
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$
d Other . .
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$
2
Return for year of loss, unused credit, or
overpayment under section 1341(b)(1)
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a Tax year ended 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
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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 . . . . . . . . . . . . . . . . . . . .
Yes No
5a
Was a consolidated return filed for any carryback year or did the corporation join a consolidated group (see instructions)?
Yes No
b
If “Yes,” enter the tax year ending date and the name of the common parent and its EIN, if different from above (see instructions)
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6a If Form 1138 has been filed, was an extension of time granted for filing the return for the tax year of the NOL? . .
Yes No
b
If “Yes,” enter the date to which extension was granted
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c Enter the date Form 1138 was filed .
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d Unpaid tax for which Form 1138 is in effect . . . . . . . . . . . . . . . . . . . . .
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$
7
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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9 Has the corporation filed a petition in Tax Court for the year or years to which the carryback is to be applied? . . .
Yes No
10
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 . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Computation of Decrease in Tax
See instructions.
preceding
tax year ended
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preceding
tax year ended
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preceding
tax year ended
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Note: If only filing for an unused general business
credit (line 1c), skip lines 11 through 15.
(a) Before
carryback
(b) After
carryback
(c) Before
carryback
(d) After
carryback
(e) Before
carryback
(f) After
carryback
11 Taxable income from tax return . . . .
12 Capital loss carryback (see instructions)
13 Subtract line 12 from line 11 . . . . .
14 NOL deduction (see instructions) . . .
15
Taxable income. Subtract line 14 from line 13
16 Income tax . . . . . . . . .
17 Alternative minimum tax . . . . . .
18
Base erosion minimum tax (Attach Form 8991)
19 Add lines 16 through 18 . . . . . .
20 General business credit (see instructions)
21 Other credits (see instructions) . . . .
22 Total credits. Add lines 20 and 21 . . .
23 Subtract line 22 from line 19 . . . . .
24
Personal holding company tax (Sch. PH (Form 1120))
25 Other taxes (see instructions) . . . .
26 Total tax liability. Add lines 23 through 25
27
Enter amount from “After carryback”
column on line 26 for each year . . . .
28
Decrease in tax. Subtract line 27 from line 26
29 Overpayment of tax due to a claim of right adjustment under section 1341(b)(1) (attach computation) . . . . . . .
Sign
Here
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.
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Signature of officer
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Date
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Title
Paid
Preparer
Use Only
Print/Type preparer’s name Preparer’s signature Date
Check if
self-employed
PTIN
Firm’s name
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Firm’s address
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Firm’s EIN
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Phone no.
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 11170F
Form 1139 (Rev. 10-2018)
