Form 1045 Application for Tentative Refund 2011

• Name(s) shown on return field contains Martha Sanders
• Number, street, and apartment or suite number. If a P.O. box, see page 4 of the instructions. field contains 9876 Holly Street
• City, town or post office, state, and ZIP code. If a foreign address, see page 4 of the instructions. field contains Yardley, Pennsylvania 19067
• Social security or employer identification number field contains 123-00-4567
• Daytime phone number field contains (041) 123-4567
• Foreign country name field is blank
• Foreign province/county field is blank
• Foreign postal code field is blank
• 1a. Net operating loss (loss) (Sch. A., line 25, page 2) field contains $10,000
• 2b. Date tax return was filed field contains 3-5-2012
• 7. Have you filed a petition in Tax Court for the year(s) to which the carryback is to be applied? No checkbox checked
• 8. Is any part of the decrease in tax due to a loss or credit from a tax shelter required to be registered? No checkbox checked
• 9. 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 page 3 of the instructions. No checkbox checked
• Under Computation of Decrease in Tax: 2nd preceding tax year ended 12-31-09:
• • 13. Subtract line 12 from line 11
  • • Before carryback field contains 36,750
    • After carryback field contains 26,000
  • 14. Exemptions. See instructions
  • • Before carryback field contains 3,650
    • After carryback field contains 3,650
  • 15. Taxable income. Line 13 minus line 14
  • • Before carryback field contains 33,100
    • After carryback field contains 22,350
  • 16. Income tax. See page 6 of the instructions and attach an explanation
  • • Before carryback field contains 4,544
    • After carryback field contains 2,939
  • 18. Add lines 16 and 17
  • • Before carryback field contains 4,544
    • After carryback field contains 2,939
  • 22. Subtract line 21 from line 18
  • • Before carryback field contains 4,544
    • After carryback field contains 2,939
  • 25. Total tax. Add lines 22 through 24
  • • Before carryback field contains 10,664
    • After carryback field contains 9,059
  • 26. Enter the amount from the After carryback column on line 25 for each year field contains 9,059
  • 27. Decrease in tax. Line 25 minus line 26 field contains 1,605
• Under Sign Here:
• • Your signature field contains Martha Sanders
  • Date field contains 4-12-2012

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