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

Version A, Cycle 2

1041-N

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

Form
(Rev. December 2014)

Department of the Treasury
Internal Revenue Service

For calendar year

Information about Form 1041-N and its separate instructions is at www.irs.gov/form1041n.

▶

or short year beginning

, and ending

, 20

General Information

Part I

OMB No. 1545-1776

, 20

.

1

Name of trust

2

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 the instructions.)

3c City or town, state, country, and ZIP code

Employer identification number

5

Was Form 1041 filed in the prior year?
Yes

6 Check applicable boxes:

Tax and Payments

Deductions

Income

Part II

Amended return

Final return

Change in fiduciary's name

No

Change in fiduciary's address

Tax Computation

1a
b
2a
b
3
4
5
6
7
8
9
10
11
12
13
14

Interest income . . . . . . . . . . . . . . . . . . . . . . . . .
Tax-exempt interest. Do not include on line 1a . . . . .
1b
Total ordinary dividends . . . . . . . . . . . . . . . . . . . . . .
Qualified dividends (see instructions) . . . . . . . .
2b
Capital gain or (loss) (Schedule D) . . . . . . . . . . . . . . . . . .
Other income. List type and amount ▶
Total income. Combine lines 1a, 2a, 3, and 4 . . . . . . . . . . . . . . .
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 the instructions) . . . . . . . . . . . . . . . . . . .
Total deductions. Add lines 6 through 11 . . . . . . . . . . . . . . . .
Taxable income. Subtract line 12 from line 5 . . . . . . . . . . . . . . .
Tax. If line 13 is a (loss), enter -0-. Otherwise, see the instructions and check
Multiply line 13 by 10% (.10) or
Schedule D . . . . . . .
applicable box:

15
16
17
18
19
20
21
22

Credits (see the instructions). Specify
Subtract line 15 from line 14 . . . . . . . . . . . . . .
Reserved . . . . . . . . . . . . . . . . . . . . .
Total tax. Add line 16 and line 17 (see the instructions) . . . . .
Payments (see the instructions) . . . . . . . . . . . . .
Tax due. If line 19 is smaller than line 18, enter amount owed . . .
Overpayment. If line 19 is larger than line 18, enter amount overpaid .
Amount of line 21 to be: a Credited to next year’s estimated tax ▶

.

1a

.

2a

.

3
4
5
6
7
8
9
10
11
12
13

INTERNAL USE ONLY
DRAFT AS OF
April 4, 2014

Part III

▶

.
.
.
.
.
.

▶
▶

the
▶

▶

.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.
b

. . . .
. . . .
. . . .
. . . ▶
. . . .
. . . .
Refunded ▶

14
15
16
17
18
19
20
21
22

Other Information

1

During the tax year, did the trust receive assets from a sponsoring Alaska Native Corporation? If “Yes,” see the
instructions for the required attachment . . . . . . . . . . . . . . . . . . . . . . . . .

2
3

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 calendar year, did the trust have an interest in or a signature or other authority over a
financial account in a foreign country (such as a bank account, securities account or other financial account)? See
the instructions for exceptions and filing requirements for FinCEN Form 114.

4

If “Yes,” enter the name of the foreign country ▶
To make a section 643(e)(3) election, complete Schedule D and check here (see the instructions.)

Signature of trustee or officer representing trustee

Print/Type preparer’s name

Preparer's signature

▲

Paid
Preparer
Use Only

.

.

▶

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.
▲

Sign
Here

.

Yes No

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

Date
Date

Check
if
self-employed

Firm’s name

▶

Firm's EIN

Firm's address

▶

Phone no.

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

Cat. No. 32234Q

PTIN

▶

Form 1041-N (Rev. 12-2014)

Version A, Cycle 2
Form 1041-N (Rev. 12-2014)

Schedule D

Page

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.)

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

(e) Cost or other basis

(d) Sales price

(see the instructions)

1

2
3
4

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

.

.

.

.

.

.

.

.

.

.

.

2

Short-term capital loss carryover .

.

.

.

.

.

.

.

.

.

.

.

3

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

.

.

.

.

.

.

4

INTERNAL USE ONLY
DRAFT AS OF
April 4, 2014
.

.

.

.

.

.

.

.

.

.

(

)

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.)

5

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

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

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

(e) Cost or other basis

(d) Sales price

(see the instructions)

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

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

.

.

.

.

.

.

10

.

.

.

.

.

.

.

(

)

10
Form 1041-N (Rev. 12-2014)

Version A, Cycle 2
Form 1041-N (Rev. 12-2014)

Page

3

Part III—Summary of Parts I and II
11

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.
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 in the instruction 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

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

18
19
20
21
22
23

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

14

.

.

.

.

.

.

.

17

.

.

.

.

.

.

.

18

.

.

.

.

.

.

13

INTERNAL USE ONLY
DRAFT AS OF
April 4, 2014
Enter the smaller of line 10 or 11 (above)

.

.

19

Enter the smaller of line 15 or line 16

.

.

20

.

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

.

.

.

.

.

.

.

21

Add lines 18 and 21

.

.

.

.

.

.

.

.

22

.

.

.

.

.

.

.

.

.

.

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

.

.

.

.

23
.

.

.

.

.

.

.

24

.

.

.

.

.

.

.

.

.

.

.

.

.

25

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

26

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

27

24

Enter the smaller of line 21 or line 23

25

Subtract line 24 from line 22

.

.

26

Enter the smaller of line 13 or 25

27

Subtract line 26 from line 13

28

Multiply line 27 by 10% (.10). Enter here and on page 1, line 14. Also check the Schedule D box on
that line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

28
Form 1041-N (Rev. 12-2014)

Version A, Cycle 2
Form 1041-N (Rev. 12-2014)

Schedule K

Page

Distributions to Beneficiaries

Page

(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

(b) Beneficiary’s SSN

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

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

(f) Tier IV distributions

(b) Beneficiary’s SSN

(e) Tier III distributions

4

of

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

(f) Tier IV distributions

(b) Beneficiary’s SSN

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

INTERNAL USE ONLY
DRAFT AS OF
April 4, 2014

(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

(c) Tier I distributions

(d) Tier II 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

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

(c) Tier I distributions

(b) Beneficiary’s SSN

(e) Tier III distributions

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

(f) Tier IV distributions

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

(f) Tier IV distributions

Form 1041-N (Rev. 12-2014)