Form 1045 Application for Tentative Refund

1045

Form

Application for Tentative Refund
▶

Type or print

Department of the Treasury
Internal Revenue Service
Name(s) shown on return

OMB No. 1545-0098

2015

Separate instructions and additional information are available at www.irs.gov/form1045.
▶ Do not attach to your income tax return. Mail in a separate envelope.
▶ For use by individuals, estates, or trusts.

Social security or employer identification number

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

Spouse’s social security number (SSN)

City, town or post office, state, and ZIP code. If a foreign address, also complete spaces below (see instructions).

Daytime phone number

Foreign country name

Foreign postal code

1 This application is filed
to carry back:
2a

Foreign province/county

a Net operating loss (NOL) (Sch. A, line 25)
$

b Unused general business credit
$

$
b Date tax return was filed

For the calendar year 2015, or other tax year
beginning

, 2015, and ending

c Net section 1256 contracts loss

, 20

3

If this application is for an unused credit created by another carryback, enter year of first carryback ▶

4
5

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 ▶
and b Year(s) ▶
If SSN for carryback year is different from above, enter a SSN ▶

6

If you changed your accounting period, give date permission to change was granted ▶

7

Have you filed a petition in Tax Court for the year(s) to which the carryback is to be applied?

8

9

Yes

No

Is any part of the decrease in tax due to a loss or credit resulting from a reportable transaction required to be
disclosed on Form 8886, Reportable Transaction Disclosure Statement? . . . . . . . . . . . .

Yes

No

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 instructions)? . . .

Yes

No

Computation of Decrease in Tax

preceding

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.

.

.

preceding

.

preceding

(see instructions)
tax year ended ▶
Before
carryback

Note: If 1a and 1c are blank, skip lines 10 through 15.

10

NOL deduction after carryback (see instructions)

11

Adjusted gross income

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12

Deductions (see instructions)

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.

13

Subtract line 12 from line 11

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14

Exemptions (see instructions)

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.

15
16

Taxable income. Line 13 minus line 14
Income tax. See instructions and
attach an explanation . . . . . .
Excess advance premium tax credit
repayment (see instructions) . . . .

17

.

18

Alternative minimum tax .

.

.

.

.

19

Add lines 16 through 18

.

.

.

.

.

tax year ended ▶
After
carryback

Before
carryback

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.

tax year ended ▶
After
carryback

Before
carryback

Cat. No. 10670A

After
carryback

Form 1045 (2015)

Page 2

Form 1045 (2015)

Computation of Decrease in Tax

preceding

preceding

preceding

(Continued)
tax year ended ▶
Before
carryback

20

General business credit (see instructions)

21

Net premium tax credit (see instructions)

22

Other credits. Identify .

23

Total credits. Add lines 20 through 22

24

Subtract line 23 from line 19 .

25

Self-employment tax (see instructions)

26
27

Additional medicare tax (see instructions)
Net investment income tax (see
instructions) . . . . . . . . .
Health care: individual responsibility
(see instructions) . . . . . . .

28

.

.

.

.

.

.

tax year ended ▶
After
carryback

Before
carryback

tax year ended ▶
After
carryback

.

Other taxes .

30
31

Total tax. Add lines 24 through 29 . .
Enter the amount from the “After
carryback” column on line 30 for each year

32

Decrease in tax. Line 30 minus line 31

33

Overpayment of tax due to a claim of right adjustment under section 1341(b)(1) (attach computation)

Keep a copy of
this application
for your records.

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Your signature

Date

Spouse’s signature. If Form 1045 is filed jointly, both must sign.

Date

Print/Type preparer’s name

Paid
Preparer
Use Only

.

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.

▲ ▲

Sign
Here

.

After
carryback

.

29

.

Before
carryback

Preparer’s signature

Date
Check
if
self-employed

Firm’s name ▶

Firm's EIN ▶

Firm’s address ▶

Phone no.

PTIN

Form 1045 (2015)

Page 3

Form 1045 (2015)

Schedule A—NOL (see instructions)
1

Enter the amount from your 2015 Form 1040, line 41, or Form 1040NR, line 39. Estates and trusts,
enter taxable income increased by the total of the charitable deduction, income distribution
deduction, and exemption amount (see instructions)
. . . . . . . . . . . . . . .

2
3
4
5

Nonbusiness capital losses before limitation. Enter as a positive number
Nonbusiness capital gains (without regard to any section 1202 exclusion)
If line 2 is more than line 3, enter the difference. Otherwise, enter -0- . .
If line 3 is more than line 2, enter the difference.
Otherwise, enter -0- . . . . . . . . .
5
Nonbusiness deductions (see instructions) . . . . . . . . . . .
Nonbusiness income other than capital gains (see
instructions) . . . . . . . . . . . .
7
Add lines 5 and 7 . . . . . . . . . . . . . . . . . . .
If line 6 is more than line 8, enter the difference. Otherwise, enter -0- . .
If line 8 is more than line 6, enter the difference.
Otherwise, enter -0-. But do not enter more
than line 5 . . . . . . . . . . . .
10
Business capital losses before limitation. Enter as a positive number . .
Business capital gains (without regard to any
section 1202 exclusion) . . . . . . . .
12
Add lines 10 and 12 . . . . . . . . . . . . . . . . . .
Subtract line 13 from line 11. If zero or less, enter -0- . . . . . . .
Add lines 4 and 14 . . . . . . . . . . . . . . . . . . .

6
7
8
9
10

11
12
13
14
15
16

17
18
19

20
21
22
23
24
25

1

2
3
4

6

8
. .

.

.

.

.

.

9

Section 1202 exclusion. Enter as a positive number . . . . . . . . . . . .
Subtract line 17 from line 16. If zero or less, enter -0- . . . . . . .
18
Enter the loss, if any, from line 21 of your 2015 Schedule D (Form 1040).
(Estates and trusts, enter the loss, if any, from line 20 of Schedule D (Form
1041).) Enter as a positive number
. . . . . . . . . . . . .
19
If line 18 is more than line 19, enter the difference. Otherwise, enter -0- .
20
If line 19 is more than line 18, enter the difference. Otherwise, enter -0- . . . . .
Subtract line 20 from line 15. If zero or less, enter -0- . . . . . . . . . . .
Domestic production activities deduction from your 2015 Form 1040, line 35, or Form
34 (or included on Form 1041, line 15a) . . . . . . . . . . . . . . . .

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.

17

.
.
line
.

21
22

Enter the loss, if any, from line 16 of your 2015 Schedule D (Form 1040).
(Estates and trusts, enter the loss, if any, from line 19, column (3), of
Schedule D (Form 1041).) Enter as a positive number. If you do not have a
loss on that line (and do not have a section 1202 exclusion), skip lines 16
through 21 and enter on line 22 the amount from line 15 . . . . . .

.

11

13
14
15

16

. . .
. . .
1040NR,
. . .

NOL deduction for losses from other years. Enter as a positive number . . . . . . . . .
NOL. Combine lines 1, 9, 17, and 21 through 24. If the result is less than zero, enter it here and on
page 1, line 1a. If the result is zero or more, you do not have an NOL . . . . . . . . . .

23
24
25
Form 1045 (2015)

Page 4

Form 1045 (2015)

Schedule B—NOL Carryover (see instructions)
Complete one column before going to the
next column. Start with the earliest
carryback year.
1
2

3
4
5
6
7

NOL deduction (see instructions).
Enter as a positive number . . .

9

Modified taxable income. Combine
lines 2 through 8. If zero or less, enter
-0- . . . . . . . . . . . .

12
13
14
15
16
17
18
19

20
21

preceding

tax year ended ▶

tax year ended ▶

tax year ended ▶

Taxable income before 2015 NOL
carryback (see instructions). Estates
and trusts, increase this amount by the
sum of the charitable deduction and
income distribution deduction . . .
Net capital loss deduction (see
instructions) . . . . . . . . .
Section 1202 exclusion. Enter as a
positive number . . . . . . . .
Domestic production activities
deduction
. . . . . . . . .
Adjustment to adjusted gross income
(see instructions) . . . . . . .
Adjustment to itemized deductions (see
instructions) . . . . . . . . .
Individuals, enter deduction for
exemptions (minus any amount on
Form 8914, line 6, for 2006 and
2009; line 2 for 2005 and 2008). Estates
and trusts, enter exemption amount .

11

preceding

.

8

10

preceding

NOL carryover (see instructions) .

.

Adjustment to Itemized Deductions
(Individuals Only) Complete lines 11
through 38 for the carryback year(s) for
which you itemized deductions only if
line 3, 4, or 5 above is more than zero.
Adjusted gross income before 2015
NOL carryback . . . . . . . .
Add lines 3 through 6 above
. . .
Modified adjusted gross income. Add
lines 11 and 12 . . . . . . . .
Medical expenses from Sch. A (Form
1040), line 4 (or as previously adjusted)
Medical expenses from Sch. A (Form
1040), line 1 (or as previously adjusted)
Multiply line 13 by percentage from
Sch. A (Form 1040), line 3 . . . .
Subtract line 16 from line 15. If zero or
less, enter -0- . . . . . . . .
Subtract line 17 from line 14 . . . .
Mortgage insurance premiums from
Sch. A (Form 1040), line 13 (or as
previously adjusted) . . . . . .
Refigured mortgage insurance
premiums (see instructions) . . . .
Subtract line 20 from line 19

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Form 1045 (2015)

Page 5

Form 1045 (2015)

Schedule B—NOL Carryover (Continued)
Complete one column before going to the
next column. Start with the earliest
carryback year.
22

Modified adjusted gross income from
line 13 on page 4 of the form . . .

23

Enter as a positive number any NOL
carryback from a year before 2015 that
was deducted to figure line 11 on page
4 of the form . . . . . . . . .

24
25

Add lines 22 and 23 . . . . . .
Charitable contributions from Sch. A (Form
1040), line 19 (line 18 for 2005 and 2006), or
Sch. A (Form 1040NR), line 5 (line 7 for 2005
through 2010), or as previously adjusted
Refigured charitable contributions (see
instructions) . . . . . . . . .

26
27
28

Subtract line 26 from line 25
. . .
Casualty and theft losses from Form
4684, line 18 (line 23 for 2008; line 21
for 2009; line 20 for 2005, 2006, and
2010) . . . . . . . . . . .

29

Casualty and theft losses from Form
4684, line 16 (line 21 for 2008; line 18 for
2005, 2006, and 2010; line 19 for 2009)

30
31

Multiply line 22 by 10% (.10) . . .
Subtract line 30 from line 29. If zero or
less, enter -0- . . . . . . . .

32
33

Subtract line 31 from line 28
. . .
Miscellaneous itemized deductions from Sch. A
(Form 1040), line 27 (line 26 for 2005 and 2006),
or Sch. A (Form 1040NR), line 13 (line 15 for 2005
through 2010), or as previously adjusted

34

Miscellaneous itemized deductions from Sch. A
(Form 1040), line 24 (line 23 for 2005 and 2006),
or Sch. A (Form 1040NR), line 10 (line 12 for 2005
through 2010), or as previously adjusted

35
36

Multiply line 22 by 2% (.02) . . . .
Subtract line 35 from line 34. If zero or
less, enter -0- . . . . . . . .

37

Subtract line 36 from line 33

38

Complete the worksheet in the
instructions if line 22 is more than the
applicable amount shown in the
instructions. Otherwise, combine lines
18, 21, 27, 32, and 37; enter the result
here and on line 7 (page 4) . . . .

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.

preceding

preceding

preceding

tax year ended ▶

tax year ended ▶

tax year ended ▶

.

Form 1045 (2015)