rom 709 United States Quarterly Gift Tax Return

(Section 6019 of the Internal Revenue Code) (For gifts made after December 31, 1976)
Calendar quarter(s) ending (month and year) P.. .
Department of the Tressury | For “Privacy Act” notification, see the Instructions for Form 1040.

Internal Revenue Service
Donor’s first name and middle initial Donor's last name ae E Social security number
=f Au)
Address (number and street) Ne Residence (domicile)
City, State, and Citizenshi
ity Bea Os FOS ip Yes | No

If you (the donfof) filed a previous Form 709, has your address changed since the last Form 709 wasfiled?. . . . .

A Gifts by husband or wife to third parties—Do you consent to have the gifts by you and by your spouse to third parties
during the calendar quarter(s) considered as made one-half by each of you? (See instruction 8.) . .
(if the answer is “Yes,” the following information must be furnished and the consent shown below signed by your spouse. ) YU: _
1(a) Name of spouse 1(b) Social security number YY
sf
Y

(Rev. October 1978)

\\

a

2 If the consent is effective for gifts made in a previous quarter(s) of the calendar year and no return was filed for such
previous quarter(s) (see instruction 1) and such gifts are being reported on this return (see instruction 10), write the
Previous quarter(s) ending (month and year) in addition to the current quarter ending (month and year).

3 Were you married during the entire calendar quarter(s)?_ . .

4 If the answer to 3 is “No,” check whether [1] married, [] divorced, or [] widowed, and give date > Yi,

5_Will a gift tax return for this calendar quarter(s) be filed by your spouse?

Consent of Spouse—I consent to har made by me and by my spouse to third parties during the calendar “quartert@) considered as made one-half by
each of us. We are both aware of the joint and several liability for tax created by the execution of this consent.

Spouse's signature >

1 Enter the amount from Schedule A, line (j)
2 Enter the amount from Schedule B, line (c)

3 Total (add amounts on lines 1 and 2). . . . . . soe eee
4 Tax computed on amount on line 3 (See Table A in separate instructions.)
5 Tax computed on amount on line 2 (See Table A in separate instructions.)

S| 6 Balance (subtract amount on line 5 from amount on line 4)

's| 7 Enter the amount of unified credit from Table B .

S| 8 Enter the amount of unified credit against gift tax allowable for all prior “quarters -

EH 9 Balance (subtract amount on line 8 from amount on line 7)

M5 10 Enter’ 20% of the amount allowed as specific exemption after September 8, 1976

11 Balance (subtract amount or line 10 from amount on line 9) . 1
12 Unified credit (enter the smaller of (i) amount on line 6 or (ii) amount on line 11). 12 |
13 Credit for foreign gift taxes (see instruction 20) . 13
14 Total (add amounts on line 12 and line 13) . 14
15 Tax due (subtract amount on line 14 from amount online6). . . - - - - - - - - - ‘115

Please attach the necessary supplemental documents; see instruction 15.

Under penalties of perjury, | declare that | have examined this return, including any accompanying schedules and statements, and to the best of my knowledge and belief it is
true, correct, and complete. Declaration of preparer (other than donor) is based on all information of which preparer has any knowledge.

Please attach Check or Money Order here

Donor's signature > Date bm
Preparer’s signature
(other than donor) b> Date >

Preparer's address
Ll ectiter'than donor)»

263-367-1


Form 709 (Rev. 10-78)

Page 2

Scie Computation of Taxable Gifts

Donee’s name and address and description of gift. If the gift was made
alter by means of a trust, enter trust's identifying number Below and Donor's adiusted Date of Value at date of
attach a copy of the trust instrument is of gi gi i
1

prookt a of MI

1 Total gifts of donor © 6 1 ee ee eee
2 One-half of items 2... tO eee attributable to spouse (see instruction 11) 2.
3 Balance (subtract amount on line 2 from amount on line 1) toe ="
4 Gifts of spouse to be included (from line 2 of spouse's return) (see instruction ‘ co ee fe
5 Total gifts (add amounts on lines 3 and 4) . |S).
6 Total exclusions not exceeding $3,000 for the calendar year for each donee (except gifts 0 of future interests) _§ |
7 Total included amount of gifts (subtract amount on line 6 from amount on line5) . «we 7 |.
Deductions (see instructions 16 and 17):
8 Gift of qualified interests to spouse for this period (before annual exclusion, based on
items ............ to. .. from Schedule A) . 2. 1. ee ee ee ee LB
9 Annual exclusion attributable to giftsonline8 . . . . re aoe
10 Net amount (subtract amount on line 9 from amount on line 8) re ae
11 First $100,000 marital deduction. . . . eee ee ee [AE] $100,000 _
12 Marital deduction for prior periods after December 31, 176 12
13 Balance of first $100,000 marital deduction available (subtract amount on line 12
from amount on line 11 but not less than zero) . 23
14 Excess over first $100,000 marital deduction (if total of amount on line 10 plus
amount on line 12 is $100,000 or less enter zero. Otherwise, enter amount on line 8
less amount on line 13) . . . . . woe ee | a4
15 Excess over first $100,000 for prior periods (after December 31, 1976) eee ee [ABE
16 Total excess over first $100,000 (add amounts on lines 14and15) . . . . . . 16 _
17 Second $100,000. . . . . (47 $100, 000
18 Gifts qualifying for additional marital | deduction (subtract ‘amount on line 17 from
amount on line 16 but not less than zero). . . . 2 1). ee ee ee |
19 Enter 50% of amount online18 . . . eee ee |B
20 Enter 50% of amount on line 8 but not more than amount online10.. . . . . [20
21 Enter the lesser of the amount on line 10 or the amount on line13. . 21
22 Marital deduction (if amount on line 18 is zero, enter amount on line 21. Otherwise,
enter amount on line 21 plus the lesser of the amounts on line 19 or line20) . . . |_22_
23 Charitable, public, and similar gifts (based on items ...... _ less
exclusions)... . oe ee ee ee ee | 28
24 Total deductions (add amounts on lines 22 and 23) . Soe ee 24 |
25 Amount of taxable gifts (subtract amount on line 24 from amount online 7)... .. | 25
Did you (the donor) file gift tax returns for prior periods? (If “Yes,” follow instruction 19 in completing Schedule B below) - L] Yes [] No
sof ers ECS Raes|_Intomal Revenue ofce whore prior return was tied | cat againn eit | esamption rpdor | Amount of
(s7t and subsequent years) Beccmnber Si: iave | Ponuary 197 oes
1 Totals for prior periods (without adjustment for reduced specific exemption) . . . |_2

2 Amount, if any, by which total specific exemption, line 1, exceeds $30,000 (see instruction 19) . . .
3 Total amount of taxable gifts for prior periods (add amount, last column, line 1, and amount, if any, line 2)

(If more space is needed, attach additional sheets of same size.)
‘Yr U.S, GOVERNMENT PRINTING OFFICE . 1978—O- 263-367

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