R-6701 (1/14)         CIT-624
                                                     Louisiana Revenue Account Number

                                                     Name
Request for a tentative refund 
resulting from the election to 
                                                     Street Address
carry back a net operating loss
Mail to:
Louisiana Department of Revenue                      City                                                State ZIP
P. O. Box 201
Baton Rouge, LA 70821-0201
FOR OFFICE USE ONLY.       Field flag

                      Schedule A:    Computation of loss amount available for carryback and carryforward
Net operating loss incurred for tax year ended ______________________                                   $

Federal tax refund or credit applicable to the loss (Attach copy of Federal Form 1139, or explanation.) $

Net operating loss available for carryback (Subtract Line 2 from Line 1.)                               $

Amount of loss utilized in Schedule B (Line 3 below)                                                    $

Net operating loss available for carryforward                                                           $

                                     Schedule B: Computation of tentative refund amount
                                     Third preceding tax year             Second preceding tax year      First preceding tax year  
                                     ended ________________               ended ________________         ended ________________
Net taxable income previously
reported
Net operating loss previously
applied
Current loss carryback
(Schedule A, Line 4)
Net taxable income (Subtract
Lines 2 and 3 from Line 1.)
Income tax liability
(Based on Line 4)

New job credits (Limited to 50%)

Other Credits

Net tax due (Subtract Lines 6
and 7 from Line 5.)

Net tax previously paid

Tentative refund (Subtract Line 9
from Line 8.)

                                                     Signature and Verification
This request is made pursuant to Revised Statute 47:287.86.G, allowing the Secretary the discretion to pay certain refunds on a tentative basis subject 
to later verification and recovery of any amount found not to be a valid overpayment under the law. I declare that I have examined this request, and to 
the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which
he has any knowledge.
Signature of Officer                          Title                       Telephone Number                        Date (mm/dd/yyyy)

Signature of Preparer                                                     Telephone Number of Preparer            Date (mm/dd/yyyy)

R-6701 (1/14)
             General Instructions

R-6701 (Form CIT-624), Request for Tentative Refund of Corporation Income Tax, may only be used to request a refund 
resulting from the carryback of a net operating loss.

Schedule A:
Schedule A is used to compute the amount of loss available for carryback, and the balance of the loss that remains to be 
carried forward. Louisiana Revised Statute 47:287.86.G provides that a net operating loss deduction may be carried back to 
each of the three taxable years preceding the taxable year in which the loss was incurred. The loss must be reduced by the 
amount of federal income tax refund or credit due to the carryback of a loss for federal income tax purposes, to the extent 
that the Federal income tax was deducted from Louisiana net income in a prior year. A schedule showing the calculation of 
the federal tax refund applicable to the loss carryback and a copy of federal Form 1139, “Corporation Application for Tentative 
Refund,” must be included with your request for tentative refund. If no federal tax refund is applicable to the loss carryback, 
a statement of explanation must be included with the refund request.

In some cases, a federal tax deduction adjustment in the prior period may be necessary even though there is no loss 
carryback for federal purposes. Federal taxes paid on income that is not being taxed by Louisiana, due to the carryback of 
the loss, cannot be deducted. This amount of adjustment to the preceding periods’ federal tax deductions may be reflected
on Schedule A, Line 2. Please attach your computation.

Schedule B:
Schedule B is used to compute the tentative refund amount requested from the appropriate preceding tax year. The current 
loss carryback (Line 3) should correspond to the total loss to be utilized as computed in Schedule A, Line 4. Any new jobs 
credits that were claimed on previous returns, but due to the election to carry back a net operating loss to that preceding 
tax period are no longer being utilized, may be carried forward and claimed against the tax liability for another period on the 
schedule. Any refund resulting from the carryforward of the new jobs credit should be included in the tentative refund amount.

A separate refund check will be issued for each period. The tax periods are subject to an examination and any tentative 
refund amounts determined not to be an overpayment may be recovered within two years from December 31 of the year in 
which the tentative refund was paid. The recovered overpayment of refund shall bear interest at the rate provided for in R.S. 
47:1601, computed from the date the tentative refund was issued until payment is received by the department.