Form 1041-N U.S. Income Tax Return for Electing Alaska Native Settle

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I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1041-N, PAGE 1 of 4
PRINTS: HEAD TO HEAD
INK: BLACK
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 432 mm (17")
279 mm (11"); FOLD TO: 216 mm (81⁄2 ")
279 mm (11")
PERFORATE: ON FOLD

Date

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

1041-N

Department of the Treasury
Internal Revenue Service

Part I

Date

or short year beginning

Signature

O.K. to print
Revised proofs
requested

U.S. Income Tax Return for Electing
Alaska Native Settlement Trusts

Form
(Rev. January 2005)

For calendar year

Action

OMB No. 1545-1776

See the separate instructions.
, 20
, and ending

, 20

.

General Information

1

Name of trust

2

Employer identification number

3a

Name and title of trustee

4

Name of sponsoring Alaska Native Corporation

3b

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

3c

City or town, state, and ZIP code

5

Was Form 1041 filed in the prior year?
Yes

6

Check applicable boxes:

Income
Deductions
Tax and Payments
2
3

4

Change in fiduciary’s name

Change in fiduciary’s address

1a

Interest income
Tax-exempt interest. Do not include on line 1a
Total ordinary dividends
Qualified dividends (see instructions)
Capital gain or (loss) (Schedule D)
Other income. List type and amount

Total income. Combine lines 1a, 2a, 3, and 4

1b
2a
2b

Taxes
Trustee fees
Attorney, accountant, and return preparer fees
Other deductions not subject to the 2% floor (attach schedule)
Allowable miscellaneous itemized deductions subject to the 2% floor
Exemption (see page 4 of the instructions)
Total deductions. Add lines 6 through 11

13
14

Taxable income. Subtract line 12 from line 5
Tax. If line 13 is a (loss), enter -0-. Otherwise, see page 4 of the instructions and check the


applicable box:
Multiply line 13 by 10% (.10) or
Schedule D
Credits (see page 4 of the instructions). Specify

Net tax. Subtract line 15 from line 14 (see page 4 of the instructions)


Payments (see page 4 of the instructions)
Tax due. If line 17 is smaller than line 16, enter amount owed
Overpayment. If line 17 is larger than line 16, enter amount overpaid
Amount of line 19 to be: a Credited to next year’s estimated tax

b Refunded

15
16
17
18
19
20

3
4
5
6
7
8
9
10
11
12
13

6
7
8
9
10
11
12

Part III
1

Final return

Tax Computation

Part II
1a
b
2a
b
3
4
5

Amended return

No

14
15
16
17
18
19
20

Other Information

During the tax year, did the trust receive assets from a sponsoring Alaska Native Corporation? If “Yes,” see
page 4 of the instructions for the required attachment
During the year, did the trust receive a distribution from, or was it the grantor of, or the transferor to, a foreign trust?
At any time during the year, did the trust have an interest in or a signature or other authority over a bank, securities,
or other financial account in a foreign country? See page 4 for exceptions and filing requirements for Form TD F 90-22.1
If “Yes,” enter the name of the foreign country



To make a section 643(e)(3) election, complete Schedule D and check here (see page 4 of the instr.)

Sign
Here
Paid
Preparer’s
Use Only

Yes No

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer (other than trustee) is based on all information of which preparer has any knowledge. Also, under
section 646(c)(2) of the Internal Revenue Code, if this is the initial Form 1041-N filed for the above-named Alaska Native Settlement Trust, signing and filing this
return will serve as the statement by the trustee electing to treat such trust as an Electing Alaska Native Settlement Trust.

Signature of trustee or officer representing trustee

Preparer’s
signature

Firm’s name (or
yours if self-employed),
address, and ZIP code

May the IRS discuss this return
with the preparer shown below
(see instr.)?
Yes
No

Date
Date

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 1041-N.

Preparer’s SSN or PTIN

Check if selfemployed

EIN
Phone no. (
Cat. No. 32234Q

)
Form

1041-N

(Rev. 1-2005)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1041-N, PAGE 2 of 4
PRINTS: HEAD TO HEAD
INK: BLACK
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 432 mm (17")
279 mm (11"); FOLD TO: 216 mm (81⁄2 ")
279 mm (11")
PERFORATE: ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page

Form 1041-N (Rev. 1-2005)

Schedule D

2

Capital Gains and Losses

Part I—Short-Term Capital Gains and Losses—Assets Held One Year or Less
(a) Description of property
(Example, 100 shares 7%
preferred of “Z” Co.)

(b) Date
acquired
(mo., day, yr.)

(c) Date sold
(mo., day, yr.)

(d) Sales price

(f) Gain or (loss)
for the entire year
(col. (d) less col. (e))

(e) Cost or other basis
(see page 5 of the instructions)

1

2

Short-term capital gain or (loss) from other forms or schedules

2

3

Short-term capital loss carryover

3

4

Net short–term gain or (loss). Combine lines 1 through 3 in column (f)

4

(

)

Part II—Long-Term Capital Gains and Losses—Assets Held More Than One Year
(a) Description of property
(Example, 100 shares 7%
preferred of “Z” Co.)

(b) Date
acquired
(mo., day, yr.)

(c) Date sold
(mo., day, yr.)

(d) Sales price

(f) Gain or (loss)
for the entire year
(col. (d) less col. (e))

(e) Cost or other basis
(see page 5 of the instructions)

5

6

Long-term capital gain or (loss) from other forms or schedules

6

7

Capital gain distributions

7

8

Enter gain, if applicable, from Form 4797

8

9

Long-term capital loss carryover

9

10

Net long-term gain or (loss). Combine lines 5 through 9 in column (f)

(

)

10
Form

1041-N

(Rev. 1-2005)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1041-N, PAGE 3 of 4
PRINTS: HEAD TO HEAD
INK: BLACK
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 432 mm (17")
279 mm (11"); FOLD TO: 216 mm (81⁄2 ")
279 mm (11")
PERFORATE: ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page

Form 1041-N (Rev. 1-2005)

3

Part III—Summary of Parts I and II
Combine lines 4 and 10 and enter the result. If a loss, go to line 12. If a gain, also enter the gain
on page 1, line 3, and complete page 1 through line 13
Next: Skip line 12 (below) and complete Part IV (below) if line 13 on page 1 is greater than zero and: a)
line 2b on page 1 is greater than zero; or b) Schedule D, lines 10 and 11, are both greater than zero.
11

12

If line 11 is a loss, enter here and on page 1, line 3, the smaller of the loss on line 11 or ($3,000).
Then complete page 1 through line 13

11

12 (

)

Next: If the loss on line 11 is more than ($3,000), or if page 1, line 13, is less than zero, skip Part IV
below and complete the Capital Loss Carryover Worksheet on page 5 before completing the rest of
Form 1041-N. Otherwise, skip Part IV below and complete the rest of Form 1041-N.

Part IV—Tax Computation Using Maximum Capital Gains Rates
13

13

Enter the taxable income from page 1, line 13

14

Enter the qualified dividends from page 1, line 2b

15

Enter the amount from Form 4952, line 4g

15

16

Enter the amount from Form 4952, line 4e

16

17

Subtract line 16 from line 15. If zero or less, enter -0-

17

18

Subtract line 17 from line 14. If zero or less, enter -0-

18

19

Enter the smaller of line 10 or 11 (above)

19

20

Enter the smaller of line 15 or line 16

20

21

Subtract line 20 from line 19. If zero or less, enter -0-

21

22

Add lines 18 and 21

22

23

Add line 18 from the Unrecaptured Section 1250
Gain Worksheet and line 7 from the 28% Rate
Gain Worksheet and enter the amount here

24

Enter the smaller of line 21 or line 23

24

25

Subtract line 24 from line 22

25

26

Enter the smaller of line 13 or 25

26

27

Multiply line 26 by 5% (.05)

28

Subtract line 26 from line 13

29

Multiply line 28 by 10% (.10)

29

30

Add lines 27 and 29. Enter here and on page 1, line 14. Also check the Schedule D box on that line

30

14

23

27
28

Form

1041-N

(1-2005)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1041-N, PAGE 4 of 4
PRINTS: HEAD TO HEAD
INK: BLACK
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 432 mm (17")
279 mm (11"); FOLD TO: 216 mm (81⁄2 ")
279 mm (11")
PERFORATE: ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 1041-N (Rev. 1-2005)

Schedule K

Page

Distributions to Beneficiaries

(a) Beneficiary’s name, street address, city, state, and ZIP code

(c) Tier I distributions

(d) Tier II distributions

(e) Tier III distributions

(a) Beneficiary’s name, street address, city, state, and ZIP code

(c) Tier I distributions

(d) Tier II distributions

(d) Tier II distributions

(a) Beneficiary’s name, street address, city, state, and ZIP code

(c) Tier I distributions

(d) Tier II distributions

(a) Beneficiary’s name, street address, city, state, and ZIP code

(c) Tier I distributions

(d) Tier II distributions

(a) Beneficiary’s name, street address, city, state, and ZIP code

(c) Tier I distributions

(d) Tier II distributions

(g) Total distributions
(Add amounts in (c) through (f))

(f) Tier IV distributions

(b) Beneficiary’s SSN

(e) Tier III distributions

(g) Total distributions
(Add amounts in (c) through (f))

(f) Tier IV distributions

(b) Beneficiary’s SSN

(e) Tier III distributions

(g) Total distributions
(Add amounts in (c) through (f))

(f) Tier IV distributions

(b) Beneficiary’s SSN

(e) Tier III distributions

(g) Total distributions
(Add amounts in (c) through (f))

(f) Tier IV distributions

(b) Beneficiary’s SSN

(e) Tier III distributions

of

(g) Total distributions
(Add amounts in (c) through (f))

(f) Tier IV distributions

(b) Beneficiary’s SSN

(e) Tier III distributions

(a) Beneficiary’s name, street address, city, state, and ZIP code

(c) Tier I distributions

Page
(b) Beneficiary’s SSN

4

(g) Total distributions
(Add amounts in (c) through (f))

(f) Tier IV distributions

Form

1041-N

(Rev. 1-2005)