United States Additional Estate Tax Return

Under Code Section 2057

Form 706-D

(Rev. October 2003) OMB No. 1545-1680

Department of the Treasury

Internal Revenue Service

General Information

1a Name of qualified heir 2 Qualified heir’s social security number

1b Address of qualified heir (number and street, including apt. no., P.O. box, or rural route) 3 Commencement date (see instructions)

1c City, town or post office, state, and ZIP code

4 Decedent’s name reported on Form 706 5 Decedent’s social security number 6 Date of death

Tax Computation (First complete Schedules A and B—see instructions.)

Qualified heir’s share of the total qualified family-owned business interests (from line 4, Schedule T,

of the decedent’s estate tax return)

1

1

Total reported value of qualified family-owned business interests (from line 6, Schedule T, of the

decedent’s estate tax return)

2

2

3 Decedent’s estate tax:

3a

Recomputed without the qualified family-owned business interest

deduction (attach computation)

a

b Reported on Form 706 (or as finally agreed to) 3b

c Gross additional estate tax (subtract line 3b from line 3a) 3c

4 % Qualified heir’s percentage of qualified family-owned business interests. Divide line 1 by line 2. Enter

result as a percentage (carry out your answer to at least the nearest tenth of a percent)

4

5 Qualified heir’s share of total reduction in estate tax. Multiply line 3c by line 4 5

6 Enter the Total from column (E), Schedule A, page 2

%

Divide line 6 by line 1. Enter the result as a percentage (carry out your answer to at least the nearest

tenth of a percent)

7

7

8 Multiply line 5 by the percentage on line 7 8

9 Applicable percentage (see instructions) 9

10 Total additional estate tax. Multiply line 8 by the percentage on line 9 10

11

15

11

12

13

15

If you completed Schedule B, complete lines 11 through 15. If you did not complete Schedule B, skip lines 11 through 14 and enter the

amount from line 10 on line 15.

Enter the total cost or fair market value (FMV) from column (C), Schedule B, page 2

%

Enter the total of column (D), Schedule A, page 2

Divide line 11 by line 12. Enter the result as a percentage (carry out your answer to at least the nearest

tenth of a percent) (do not enter more than 100%)

Additional estate tax due. Subtract line 14 from line 10 (do not enter less than zero)

Part I

Part II

Cat. No. 26107A Form 706-D (Rev. 10-2003)

6

%

14 Multiply line 10 by the percentage on line 13

12

13

14

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 taxpayer) is based on all information of which preparer has any knowledge.

Sign

Here  Signature of taxpayer or person filing on behalf of taxpayer Date

Date Preparer’s Paid signature

Preparer’s

Use Only Preparer’s name

and address ZIP code 




Form 706-D (Rev. 10-2003) Page 2

Schedule A. Disposition of Qualified Family-Owned Business Interest, Failure to Materially

Participate, or Disqualifying Act (Taxable Under Section 2057(f)(1))

(C) (D)

(B) (A) Amount realized or fair

market value (FMV) if

applicable (see instructions)

Date of disposition, failure to

materially participate, or

disqualifying act (see instructions)

Description of property and explanation of disqualifying act Item

number

Total. Enter the total of column (D) on line 12 of Part II, Tax Computation,

page 1, and the total of column (E) on line 6 of the Tax Computation

Schedule B. Involuntary Conversions or Exchanges

(C)

(A) (B) Cost or fair

market value

(FMV)

Item Description of qualified replacement (or exchange) property

Total. Enter the total of column (C) on line 11 of Part II, Tax Computation, page 1.

Check if for Involuntary Conversion Exchange

Schedule C. Nontaxable Transfers

(C)

(A) (B) Date of disposition,

contribution, trust agreement,

or bond

Item Description of property and explanation of nontaxable transfers

Transferee

Last name First name Middle Initial

Social security number Relationship to the qualified heir

1 Form 706, Schedule , Item 

Description —

1 Form 706, Schedule , Item 

Description —

1

(E)

Date of death value (see

instructions)

Check if for Qualified Conservation Contribution Loss of U.S. Citizenship Disposition to Family Member

Form 706-D (Rev. 10-2003)