corm 5329 Return for Individual 1975

Retirement Savings Arrangement

imomal Revenue Sore” (Under Sections 408 or 409 of the Internal Revenue Code) Only This Side of Form is
® Attach to Form 1040. Open to Public Inspection

Any individual who has established a retirement savings arrangement must complete Part | and Part II and attach
this form to their individual income tax return, Form 1040. In addition: (1) if you claim a deduction on your Form 1040
for contributions to your retirement savings arrangement, complete Part Ill; (2) if you have made contributions in
excess of your allowable limitation for this year or prior years, complete Part IV; (3) if you are not yet age 5914
when you receive a distribution from your retirement savings arrangement which is not due to a disability, a rollover
contribution to another plan or arrangement, or the transfer of an amount to a former spouse under a divorce decree,
you must complete Part V.

Name Your social security number

‘Address (Number and street)

IRA |

City or town, State and ZIP code

If you are not required to filea Form 1040 checkhere . . . ee ee ee ee ee ee ee et tle OD

Individual and Retirement Savings Information

1 Type of funding arrangement:

(a) [] Individual retirement account
(b) [Fj Individual retirement annuity
(c) [J Individual retirement bonds

2 Were you during any part of the year an active participant in a qualified pension, profit-sharing or stock
bonus plan, including a qualified Keogh (HR 10) plan (see instructions), or were you covered under a
section 403(b) annuity or custodial account or under a government retirement plan other than the Social
Security or Railroad Retirement Acts? - 6 6 ee ee te et ee ee ee ee ee GP Yes = NO

Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief it is true, correct, and complete. If prepared by a person other than the taxpayer, this declaration is based on all information
of which the preparer has any knowledge.

Your signature

Date

16—82709-1 Form 5329 «1975)


Form 5329 (1975) This Page Is Not Open to Public Inspection Page 2

Attach Copy B of Form 5498 here >

3 If filed by surviving spouse or beneficiary of an individual who created this retirement savings arrangement check here ® [1]
and enter name and social security number of individual for whom the arrangement was established > ___

4 Indicate your age as of the end of the year:
(a) [] Under age 5914
(b) FJ Age 591% to 7016
(c) Fj Over age 70

Do not complete items 5 through 7 unless you have:

p> Transferred your entire interest from a qualified pension, profit-sharing or stock bonus plan to your retirement
savings arrangement—Complete item 5.

> Transferred any funds from one retirement savings arrangement to another retirement savings arrangement—
Complete item 6.

p Entered into a prohibited transaction—Complete item 7.

5 (a) If, during the year, you received a lump sum distribution of your entire account from a = qualified pension,

profit-sharing or stock bonus plan, check here. . . . . ee os rs |
(b) If you checked (a) did you transfer the entire amount of the distribution which exceeded your contributions

(see instructions) to your individual retirement savings arrangement within 60 days of receipt? . . [] Yes [J No
(c) If (b) above was “Yes,”” complete lines (i) through (iii) below: Month; Day { Year

(i) Dateoftransfer. 2. 1. 1 fe we ee ee

(ii) Date distribution was madeto you. 6 2 6 2 ee
(iii) Name of trustee or insurance company to which transfer was made (if bonds were purchased state “Bonds’

Caution: Such a transfer may be considered a ‘‘rollover contribution” (see instructions) and not deductible.

ra ; . Month: D; !
6 If, during the year, you transferred any funds from one individual retirement savings arrangement to another | Month Day ; Year

individual retirement savings arrangement, enter the date of transfer here
Caution: (1) Such a transfer may be considered a “rollover contribution” (see instructions) and not deductible;
(2) Such a transfer may be a taxable distribution.

7 If you have entered into a prohibited transaction under section 4975 or borrowed any amount from your retirement savings
arrangement or pledged any part of your arrangement as security foraloan,checkhere. . - - 2... . e+
Note: See instructions for the tax consequences of such transactions.

EEZTEAIE Computation of Allowable Deduction

(If you have entered into a prohibited transaction under section 4975, do not complete Part III or Part
IV for the retirement savings arrangement with which you entered into such prohibited transaction.)

8 Wages, tips and other compensation (see definition B) from Form 1040 (if a joint return do not include :
compensation of spouse). . a i

9 15% of line 10 or Sus 500, whichever is lesser a you are age 70% or over or answered ‘‘Yes’’ to line 2,
enter zero) . . .

10 Amount paid by you or on your behalf f under all your individual retirement savings ‘arrangements (do not
include any amounts which were considered as “rollover contributions,” see lines 5 and 6, or the purchase
price of any individual retirement bonds redeemed within 12 months of their date of purchase (see instruc-
tions) or life insurance portion of your endowment premium as reported on Form 5498 box 6) . toe

11 Allowable deduction, lesser of line 9 or line 10 (enter here and on Form 1040, line 40b) . . - - se
[zal Tax on Excess Contributions
12 Tax on excess contributions (see Part IV of the ve Specific Instructions if Part III, line 10 exceeds line 11). Enter |
here and on Form 1040, line62.. . . we i

MGT Tax on Premature Distributions

13 Tax on premature distributions (see Part V of the Specific Instructions if you received a distribution from

your retirement savings arrangement before you have attained age 5914). Enter here and on Form 1040,
line58. . . ee ee
‘Yr US. GOVERNMENT PRINTING OFFICE: 1975—O-562-638 16—82700-1